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NATIONAL LIBRARY OF MEDICINE 
Bethesda, Maryland 











FIRST LINES 



OF THE 



PRACTICE OF PHYSIC 



WILLIAM CULLEN, M. D. 

LATE PROFESSOR OFTHE PRACTICE OF PHYSIC IN THE 
UNIVERSITY OF EDINBURGH, &C. 



WITH PRACTICAL AND EXPLANATORY 
NOTES, 

BY JOHN ROTHERAM, M. D. 



IN TWO VOLUMES. 



VOL. II. 



NEW-YORK 



PRINTED BY L. NICHOLS, 
FOR I. RILEY & Co. BOOK-SELLERS & STATIONERS, 

NO. 1, CITY-HOTEL, BROADWAY. 
1805. 



)US 



CONTENTS 

OF THE 

SECOND VOLUME. 



BOOK IV. 



PAGE 



CHAP. VI. 

CHAP. VII. 
CHAP. VIII 
CHAP. IX. 

Sect. I. 

Sect. II. 



CHAP. I. 
CHAP. II. 



CHAP. I. 
CHAP. II. 



CHAP. I. 
CHAP. II. 
CHAP. III. 



Sect. I. 
CHAP. I. 
CHAP. II. 
CHAP. III. 



r. 

OF the Menorrhagia, or the immoderate flow of 

the Menses 305 

Of the Leucorrhaa, Fluor Albus, or Whites 310 

Of the Amenorrhea, or Interruption of the Menses 313 
Of Symptomatic Hemorrhages 318 

Of the Hematemesis, or Vomiting of Blood 
Of the Hematuria, or the voiding of Blood from 
the Urinary Passage 

BOOK V. 

Of Profluvia, or Fluxes t with Pyrexia 
Of the Catarrh 
Of the Dysentery 

PART II. 

Of Neuroses, or Nervous Diseases 

BOOK I. 

Of Comata, or the Loss of Voluntary Motion 
Of Apoplexy 
Of Palsy 

BOOK II. 

Of Adynamia, or Diseases consisting in a weakness 
or loss of Motion in either the vital or natural 
Functions ?68 

Of Syncope or Fainting » bl d 

Of Dispepsia, or Indigestion < 374 

Of Hypochondriasis, or the Hypochondriac Affec- 
tion, commonly called Vapors or Low Spirits 385 

BOOK III. 

Of Spasmodic Affections without Fever 392 

Of the Spasmodic Affections of the Animal Functions 393 

°f T ' ta r lit 

Of Epilepsy ™ 

Of the Chorea, or Danct of St. Vitus 421 



325 

530 
ibid 
336 

343 

344 
ibid 
358 



CONTENTS. 



Sect. II. Of the Spasmodic Affections of the Vital Functions 423 
CHAP. IV. Of the Palpitation of the Heart ibid 

CHAP. V. Of Dyspnoea, or Difficult Breathing 425 

CHAP. VI. Of Asthma 427 

CHAP. VII. Of the Chincough, or Hooping Cough 434 

Sect. III. Of the Spasmodic Affections in the Natural Func- 
tions 
CHAP. VIII. Of the Pyrosis, or what is named in Scotland, the 

Water-Brash 
CHAP. IX. Of the Colic 
CHAP. X. Of the Cholera 
CHAP. XI. Of Diarrhoea, or Looseness 
CHAP. XII. Of the Diabetes 

CHAP. XIII. Of the Hysteria, or the Hysteric Disease 
CHAP. XIV. Of Canine Madness and Hydrophobia 

BOOK IV. 

Of VesanU, or of the Disorders of the Intellectual 
Functions 
CHAP. I. Of Vesanit in general 
CHAP. II. Of Mania, or Madness 
CHAP. III. Of Melancholy, and other forms of Insanity 

PART III. 

Of Cachexies 

BOOK I. 

Of Emaciations 

BOOK II. 

Of Intumesccntia, or General Swellings 
CHAP. I. Of Adipose Swellings 

CHAP. II. Of Flatulent Swellings 
CHAP. III. Of Watery Swellings, or Dropsies 
Sect. I. Of Anasarca 

Sect. II. Of the Hydrothorax, or dropsy of the Breast 
Sect. III. Of the Ascites, or Dropsy of the Lower Belly 
CHAP. IV. Of General Swellings, arising fr»m an increased 

bulk of the whole substance of particular parts 544 
Of Rachitis, or Rickets 545 

BOOK III. 

Of the Impetigines, or depraved habit, with Af- 
fections of the Skin 553 
CHAP. I. Of Scrophula, or the Kings Evil 554 
CHAP. II. Of Siphy lis, or the Venereal Disease 561 
CHAP. III. Of Scurvy 572 
CHAP. IV. Of Jaundice 578. 



442 

ibid 
444 
451 
454 
465 
468 
473 



474 
ibid 
485 
492 

499 

ibid 

508 
ibid 
511 
518 
527 
537 
541 



FIRST LINES 

OF THE 

PRACTICE OF PHYSIC. 
BOOK IV. 

CHAPTER VI. 

OF THE MENORRHAGIA, OR THE IMMODE- 
RATE FLOW OF THE MENSES. 

965. ] T3LOOD discharged from the vagina may pro- 
J3 ceed from different sources in the internal parts : 
but I here mean, to treat of those discharges only, in which 
the blood may be presumed to flow from the same sources 
that the menses in their natural state proceed from ; and 
which discharges alone, are those properly comprehended 
under the present title. The title of Metrorrhagia, or ha- 
otorrhagia uteri, might comprehend a great deal more. 

966.] The menorrhagia may be considered as of two 
kinds ; either as it happens to pregnant and lying-in women, 
or as it happens to women neither pregnant nor having re- 
cently born children. The first kind, as connected with the 
circumstances of pregnancy and child-bearing, (which are 
not to be treated of in the present course) I am not to con- 
sider here, but shall confine myself to the second kind of 
menorrhagia only. 

967.] The flow of the menses is considered as immode- 
rate, when it recurs more frequently,* when it continues 
longer, or when, during the ordinary continuance,f it is 
more abundant^ than is usual with the same person at other 
times. 

968.] As the most part of women are liable to some in- 
equality with respect to the period, the duration, and the 

* The usual period is from twenty-seven to thirty days. 

+ The time of its continuance is very various in different people ; it seldom continues longer 
than eight days or shorter than two In general, women of a lax and delicate constitution have 
a more copious and a longer continued discharge than robust people. 

t It is extremely difficult to ascertain precisely what quantity is usually discharged ; but the 
women themselves can generally iniorm the physician with sufficient exactness for regulating the 
practice whether the discharge be immoderate. 

2r 



306 PRACTICE OF PHYSIC. 

quantity of their menses ; so it is not every inequality in 
these respects that is to be considered as a disease ; but only 
those deviations, which are excessive in degree, which are 
permanent, and which induce a manifest state of debility. 

969.] The circumstances (967. 968.) are those which 
chiefly constitute the menorrhagia : but it is proper to ob- 
serve, that although I allow the frequency, duration, and 
quantity of the menses to be judged of by what is usual 
with the same individual at other times ; yet there is, in 
these particulars, so much uniformity observable in the 
whole of the sex, that in any individual in whom there oc- 
curs a considerable deviation from the common measure, 
such a deviation if constantly recurring, may be consider- 
ed as at least approaching to a morbid state, and as requiring 
most of the precautions which I shall hereafter mention as 
necessary to be attended to by those who are actually in such 
a state. 

970.] However we may determine with respect to the 
circumstances (967. 968.) it must still be allowed, that the 
immoderate flow of the menses is especially to be determined 
by those symptoms affecting other functions of the body, 
which accompany and follow the discharge. 

When a larger Mow than usual of the menses has been 
preceded by headach, giddiness, or despncea, and has been 
ushered in by a cold stage, and is attended with much pain 
of the back and loins, with a frequent pulse, heat, and 
thirst, it may then be considered as preternaturally large. 

971.] When, in consequence of the circumstances (967 — 
970.) and the repetition of these, the face becomes pale ; the 
pulse grows weak : an unusual debility is felt in exercise ; 
the breathing is hurried by moderate exercise ; when, also, 
the back becomes pained from any continuance in an erect 
posture ; when the extremities become frequently cold ; and 
when in the evening the feet appear affected with cedematous 
swelling ; we may from these symptoms certainly conclude, 
that the flow of the menses has been immoderate, and has 
already induced a dangerous state of debility. 

972.] The debility thus induced does often discover it- 
self also by affections of the stomach, as anorexia and 
other symptoms of dyspepsia ; by a palpitation of the heart, 
and frequent faintings; by a weakness of mind liable to 
strong emotions from slight causes, especially when sud- 
denly presented. 

973.] That flow of the menses, which is attended with 



PRACTICE OF PHYSIC. 307 

barrenness in married women, may be generally considered 
as immoderate and morbid. 

974.] Generally, also, that flow of the menses may be 
considered as immoderate, which is preceded and followed 
by a leucorrhoea. 

975. J I treat of menorrhagia here as an active hemor- 
rhagy, because I consider menstruation, in its natural state, 
to be always of that kind; and although there should be 
cases of menorrhagia which might be considered as purely 
passive, it appears to me that they cannot be so properly 
treated of in any other place. 

976. The menorrhagia (967. et scq.) has for its proximate 
cause, either the hemorrhagic effort of the uterine vessels 
preternatu rally increased, or a preternatural laxity of the 
extremities of the uterine arteries, the hemorrhagic effort 
remaining as in the natural state. 

977.] The remote causes of the menorrhagia may be, 
1st, Those which increase the plethoric state of the uterine 
vessels ; such as a full and nourishing diet, much strong li- 
quor, and frequent intoxication. Idly. Those which de- 
termine the blood more copiously and forcibly into the 
uterine vessels ; as violent strainings of the whole body ; 
violent shocks of the whole body from falls ; violent strokes 
or contusions on the lower belly ; violent exercise, particu- 
larly in dancing ; and violent passions of the mind, 'idly. 
Those which particularly irritate the vessels of the uterus ; 
as excess in venery ; the exercise of venery in the time of 
menstruation ; a costive habit, giving occasion to violent 
straining at stool ; and cold applied to the feet.* 4thly, 
Those who have forcibly overstrained the extremities of 
the uterine vessels ; as frequent abortions ; frequent child- 
bearing without nursing ;f and difficult tedious labors, 
Or, lastly, Those which induce a general laxity ; as living 
much in warm chambers, and drinking much of warm ener- 
vating liquors, such as tea and coffee. 

* II is difficult to account for this cause of menorrhagia : It may perhaps be owing to the cir- 
culation through the lower extremities being obstructed or impeded, and consequently a greater 
flow of blood to the uterus. The fact, however, is certain ; lur experience sufficiently evinces 
that menorrhagia frequently follows an imprudent expose of the feet to cold, especially damp 
coid. Sitting in wet shoes, or in a damp cold room with a stone floor, ought to be carefully 
avoided by ladies of a delicate constitution. 

+ in nursing, the fluids arc determined 10 ihe breast, and in a peculiar manner derived from 
the uterus. Thi part of the economy 01 nature physiologists have not yet sufficient!) explained, 
but the fact is well asceriaincd Nursing is not onl) useful in preventing menorrhagia, but, as 
ii derive, the fluids from the uterus, it prevents also frequent child-bearing ; and consequently, 
which is the greatest advantage of all others, time is allowed to the uterus for regaining its for- 
mer tone and strength : The subsequent child births are also rendered more easy thai, they would 
otherwise be, and the children more healthy. It would be improper to enumerate all the ad- 
vantages of nursing in this place, as 1 shall reserve the consideration of them for a future pub- 
lication. 



308 PRACTICE OF PHYSIC. 

978.] The effects of the menorrhagia are pointed out in 
971, 972. where I have mentioned the several symptoms 
accompanying the disease ; and from these the consequences 
to be apprehended will also readily appear. 

979.] The treatment and cure of the menorrhagia must 
be different, according to the different causes of the disease. 

In all cases, the first attention ought to be given to avoid- 
ing the remote causes, whenever that can be done ; and by 
that means the disease may be often entirely avoided. 

When the remote causes cannot be avoided, or when 
the avoiding them has been neglected, and therefore a co- 
pious menstruation has come on, it should be moderated 
as much as possible, by abstaining from all exercise, either 
at the coming on, or during the continuance of the men- 
struation; by avoiding even an erect posture as much as 
possible; by shunning external heat, and therefore warm 
chambers and soft beds; by using a light and cool diet; by 
taking cold drink, at least as far as former habits will allow: 
by avoiding venery ; by obviating costiveness, or remov- 
ing it by laxatives that give little stimulus.* 

The sex are commonly negligent, either in avoiding the 
remote causes, or in moderating the first beginnings of this 
disease. It is by such neglect that it so frequently becomes 
violent, and of difficult cure; and the frequent repetition 
of a copious menstruation, may be considered as a cause 
of great laxity in the extreme vessels of the uterus. 

980.] When the coming on of the menstruation has been 
preceded by some disorder in other parts of the body, and 
is accompanied with pains of the back, resembling partu- 
rient pains, together with febrile symptoms, and when at 
the same time the flow seems to be copious, then a bleed- 
ing at the arm may be proper, but it is not often necessa- 
ry ; and it will in most cases be sufficient to employ, with 
great attention and diligence, those means for moderat- 

* The laxatives that give little stimulus are manna, oil, tamarinds, cassia, and sucli mild sub- 
stance^. A.oetic, and oilier drastic purges, must be carefully avoided. Rhubarb, in moderate 
doses, is only admissible in cases where there is an evident atony of ihe stomach or intestines j 
and in these cases it ought to be given id substance, or in a watery infusion. The spirituous aiul 
vinous tinctures of it are absolutely inadmissible in menorrhagia. 

A table spoonful of the following linctus, taken occasionally, trill sufficienlly obviate costive- 
ness, without giving much stimulus: 

Be. Mann. opt. Bij. 
01. ricini 31. 
Syr. rosar. solut. I'u 
Crem. tartar. §ss. 
M. f. Linct, 



PRACTICE OF PHYSIC. 309 

ing the discharge which have been mentioned in the last 
paragraph. 

98 1. J When the immoderate flow of the menses shall 
seem to be owing to a laxity of the vessels of the uterus, 
as may be concluded from the general debility and laxity 
of the person's habit; from the remote causes that have oc- 
casioned the disease (971.) from the absence of the symp- 
toms which denote increased action in the vessels of the 
uterus (970.) from the frequent recurrence of the disease, 
and particularly from this, that in the intervals of menstru- 
ation the person is liable to aleucorrhoea ; then in such case 
the disease is to be treated, not only by employing all the 
means mentioned in 979. for moderating the hemorrha- 
gy, but also by avoiding all irritation, every irritation hav- 
ing the greater effect in proportion as the vessels have been 
more lax and yielding. If, in such a case of laxitv, it shall 
appear that some degree of irritation concurs, opiates may 
be employed to moderate the discharge; but in using these, 
much caution is requisite.* 

If, notwithstanding these measures having been taken, 
the discharge shall prove very large, astringents, f both 
external and internal, may be employed. In such cases, 
may small doses of emetics be of service? 

982.] When the menorrhagy depends on the laxity of 
the uterine vessels, it will be proper, in the intervals of men- 
struation, to employ tonic remedies ; as cold bathing and 
chalybeates.J The exercises of gestation, also, may be 

* Opiates used too liberally generally increase the discharge, in consequence of their rery 
great power In relaxing ihe whole system. 

+ The astringents for internal use, are alum, catechu, tincture of roses, &c. Ten grain: of 
»lum, and as muc'i catechu may be given in a powder, every two or three hours, with three or 
four spoonfuls of tincture of roses to wash if down. The bark is sometimes of use in these ca- 
ses, especially when joined with alum. The ex.einal applications are, cold cloths soaked in vi- 
negar mil water applied to the lower region of the abdomen, or to the pudenda ; or a strong 
decoction of oak bark, with an ounce of alum dissolved in every pint of it) may be applied 
cold to the same parts. 

t The following form is very convenient : 

R. Rubigin. ferri 3ij. 
Cort. Peruv. |i. 
Syr. simpl. q. s. 
M. f. Elect. 

The dose of this electuary U 10 be varied according to the constitution ; the size of a nutmeg 
twice a day is usually given. 

The best'lorms of chaybeates, in these cases, are the mineral waters which contain iron dis- 
solved by fixed air. Chalybeate waters should not, in this disease, be drank in such large quan- 
tities as topassoff by stool. A gill taken every three or four hours throughout the day, wnh a 
spoonful of Port wine, is more efficacious than a pint or even a quart, taken at once in the 
morning. The dose, however, of these waters, vanes according to the strength of the particu- 
lar water wc use. Along with the chalybeate water, a scruple or half a drachm of Peiuvian bark 
may be given twice a -day. 

Ihe following form is very agreeable, and is at the same time singularly efficacious: 

R. Extract, cort. Peruv. §i. 
Extract. Campechens. 



310 PRACTICE OF PHYSIC. 

very useful, both for strengthening the whole system, and 
for taking off the determination of the blood to the inter- 
nal parts. 

983.] The remedies mentioned in these two last para- 
graphs, may be employed in all cases of menorrhagia, from 
whatever cause it may have proceeded, if the disease shall 
have already induced a considerable degree of debility in 
the body. 



CHAPTER VII. 

OF THE LEUCORRH&A, FLUOR ALBUS, OR 
WHITES. 

984.] T? VERY serous or puriform discharge from the 
JLLi vagina, may be, and has been comprehended 
under one or other of the appellations I have prefixed to 
this chapter. Such discharges, however may be various ; 
and may proceed from various sources, not yet well ascer- 
tained ; but I confine myself here to treat of that discharge 
alone which may be presumed to proceed from the same 
vessels, which, in their natural state, pour out the menses. 

985.] I conclude a discharge from the vagina to be of 
this kind ;* 1. From its happening to women who are sub- 
ject to an immoderate flow of the menses, and liable to this 
from causes weakening the vessels of the uterus. 2. From 
its appearing chiefly, and often only, a little before, as well 
as immediately after, the flow of the menses. 3. From 
the flow of the menses being diminished, in proportion as 
the leucorrhoea is increased. 4. From the leucorrhcea con- 
tinuing after the menses have entirely ceased, and with 
some appearance of its observing a periodical recurrence. 
5. From the leucorrhosa being accompanied with the effects 
of the menorrhagia (971 — 972.) 6. From the discharge 
having been neither preceded by, nor accompanied with, 
symptoms of any topical affections of the uterus. 7. From 
the leucorrhcea not having appeared soon after communi- 
cation with a person who might be suspected of communi- 

Extract. Glychrrh. aa ^ss. 
Mucilag. gum. Arab. q. s. 
M. f. Elect. 

The dose is half a drachin or two scrupies twice a-day. 

*The young practitioner ought to pa) gr.;at attention to the diagnostics of the leucorrhcea de- 
livered in this article. 



PRACTICE OF PHYSIC. 31 i 

eating infection, and from the first appearance of the dis- 
ease not being accompanied with any inflammatory affec- 
tion of the pudenda.* 

986.] The appearance of the matter discharged in the 
leucorrhoea, is very various with repect to consistence and 
color ; but from these appearances, it is not always possible 
to determine concerning its nature, orthe particular source 
from whence it proceeds. 

987.] The leucorrhoea, of which I am to treat, as ascer- 
tained by the several circumstances (985.) seems to proceed 
from the same causes as that species of menorrhagia which 
I suppose to arise from the laxity of the extreme vessels of 
the uterus. It accordingly often follows or accompanies 
such a menorrhagia ; ; but though the leucorrhoea depends 
chiefly upon the laxity mentioned, it may have proceeded 
from irritations inducing that laxity, and seems to be always 
increased by any irritations applied to the uterus. 

988.] Some authors have alleged, that a variety of cir- 
cumstances in other parts of the body may have a share in 
bringing on and in continuing this affection of the uterus 
now under consideration ; but I cannot discover the reality 
of those causes ; and it seems to me, that this leucorrlicra, 
excepting in so far as it depends upon a general debility of 
the system, is always primarily an affection of the uterus ; 
and the affections of other parts of the body which may 
happen to accompany it, are for the most part to be consi- 
dered as effects, rather than as causes. 

989.] The effects of the leucorrhoea are much the same 
with those of menorrhagia ; inducing a general debility, 
and in particular, a debility in the functions of the stomach. 
If, however, the leucorrhoea be moderate, and be not ac- 
companied with any considerable degree of menorrhagia, 
it may often continue long without inducing any great de- 
gree of debility, and it is only when the discharge has been 
very copious as Avell as constant, that its effects in that way 
are very remarkable. 

990.] But, even when its effects upon the whole body are 
not very considerable, it may stillbe supposed to weaken the 

* Nothing is more frequent with ignorant practitioners than to mistake a gonorrhoea for a leu- 
corrhoea. Women in general give the name of whites to a gonorrhoea, and therefore the unwary 
practitioner may the more easily be misled. The distinguishing characierisiic of gonorrhoea is, 
is the Author says, an inflammatory affection of the pudenda ; but, as tew women will sutler 
.hi itupectton of the parts, we must pay some attention to the concomitant symptoms. The 
running m a gonorrhoea is constant, and only in small quantities ; in a leucorrhoea the discharge 
is inconstant, and in Urge quantities. The other distinguishing marks of a gonorrhoea are, 
smarting in making water, itching of tie pudenda, increased inclination for vtnery, a swelling 
ol (he labia and ot the glands about the groin. Some authors mention lh<r color of the discbarg- 
-'] nutter as - aUtingutfhine. mark ; this however, is inconstant. 



312 PRACTICE OF PHYSIC. 

genital system ; and it seems sufficiently probable that this 
discharge may often have a share in occasioning barrenness. 

991.] The matter discharged in theleucorrhcea, is at first 
generally mild ; but alter some continuance of the disease, 
it sometimes becomes acrid ;* and by irritating, or per- 
haps eroding, the surfaces over which it passes, induces 
various painful disorders. 

992.] As I have supposed that the leucorrhoea proceeds 
from the same causes as that species of menorrhagia which 
is chiefly owing to a laxity of the uterine vessels, it must 
be treated, and the cure attempted, by the same means as 
delivered in 981, for the cure of menorrhagia, and with 
less reserve in respect to the use of astringents. f 

993.] As the leucorrhoea generally depends upon a great 
loss of tone in the vessels of the uterus, the disease has 
been relieved, and sometimes cured by certain stimulant 
medicines, which are commonly determined to the urinary 
passages, and from the vicinity of these are often commu- 
nicated to the uterus. Such, for example, are cantharides, 
turpentine, and other balsams of a similar nature.J 

•Theyoum; practitioner must not conclude too hastily that an ulcer exists in the uterus when 
the ma tier discharged is acrid. Practice has afforded many instances where the matter has ex- 
coriated the pudenda, and yet no ulcer existed. 

+ The electuary mentioned at the end of the last note on article 982. has been found effica- 
cious in some cases of leucorrhoea. Its dose may be increased to a drachm ilnice a-day, either 
swallowed as a bolus, or dissolved in an ounce of pure water, and half an ounce of simple cin- 
namon wjter. 

The oha.ybeate waters are useful in this, as well as in the former disease ; and they may be 
used in the manner above mentioned. 

Practitioners recommend, in these cases, a nutritive but not a heating diet, as mucilaginous, 
broths made with rice, especially veal-broih, jelhesof all kinds, except those that are high-sea- 
soned. Port wine must be prescribed in a moderate quantity, according to the habits of the 
patient. 

t The practice here recommended is not without danger, and must not be followed except 
with great caution and circumspection. When the other means fail producing relief, we may 
then have recourse to these balamics, or join them to the tonic astringents, as, 

ft. Gum. oliban. 
Terebinth, venet. 
Alum. 

Terr. Japonic, aa. 3i. 
Sal. martis 3ss. 
M. f. massa. in pilulas asquales No. 60. dividend. 

Two or three of these pills may be given twice a day or ofiener. 
Some practitioners have strongly recommended the following emulsion. 

R. Balsam, copaivi. 3i, 
Vitel. ovi No. 1. 

Tere in mortar, marmor. et adde gradatim, 
Aq. font. ^vii. 
Syr. Simpl. §i. 

M. f. Emuls. 
The dose of this emulsion is two or three spoonfuls three or four times a d«y. 



PRACTICE OF PHYSIC. 313 



CHAPTER VIII. 

OF THE AMENORRHEA, OR INTERRUPTION 
OF THE MENSTRUAL FLUX. 

994.] IT 7HATEVER, in a system of methodical no- 
V V sology, may' be the fittest place for the ame- 
norrhoea, it cannot be improper to treat of it here as an ob- 
ject of practice, immediately after having considered the 
menorrhagia. 

995.] The interruption of the menstrual flux is to be 
considered as of two different kinds ; the one being when 
the menses do not begin to flow at that period of life at 
which they usually appear ; and the other being that when, 
after they have repeatedly taken place for some time, they 
do, from other causes than conception, cease to return at 
their usual periods : The former of these cases is named 
the retention, and the latter the suppression, of the menses. 

996.] As the flowing of the menses depends upon the 
force of the uterine arteries impelling the blood into their 
extremities, and opening these so as to pour out red blood ; 
so the interruption of the menstrual flux must depend, either 
upon the want of due force in the action of the uterine ar- 
teries, or upon some preternatural resistance in their extre- 
mities. The former I suppose to be the most usual cause of 
retention, the latter the most common cause of suppres- 
sion ; and of each of these I shall now treat more particu- 
larly. 

997.] The retention of the menses, the emansio mensiuvi 
of Latin writers, is not to be considered as a disease merely 
from the menses not flowing at that period which is usual 
with most other women. This period is so different in dif- 
ferent women, that no time can be precisely assigned as 
proper to the sex in general. — In this climate, the menses 
usually appear about the age of fourteen, but in many they 
appear more early, and in many not till the sixteenth year : 
in which last case it is often without any disorder being 
thereby occasioned. It is not therefore from the age of the 
person that the retention is to be considered as a disease ; 
and it is only to be considered as such, when about the time 
the menses usually appear, some disorders arise in other 
parts of the body which may be imputed to their retention ; 

2s 



314 PRACTICE OF PHYSIC. 

being such as, when arising at this period, are known from 
experience to be removed by the flowing of the menses. 

998.] These disorders are, a sluggishness, and frequent 
sense of lassitude and debility, with various symptoms of 
despepsia ; and sometimes with a preternatural appetite.* 
At the same time the face loses its vivid color, becomes 
pale, and sometimes of a yellowish hue ; the whole body be- 
comes pale and flaccid ; and the feet, and perhaps also a 
great part of the body, become affected with oedematous 
swellings. The breathing is hurried by any quick or laborious 
motion of the body, and the heart is liable to palpitation and 
syncope. — A headach sometimes occurs; but more certainly 
pains of the back, loins, and haunches. f 

999.] These symptoms, when occurring in a high de- 
gree, constitute the chlorosis of authors, hardly ever ap- 
pearing separate from the retention of the menses ; and, at- 
tending to these symptoms, the cause of this retention may, 
I think, be perceived. 

These symptoms manifestly show a considerable laxity 
and flacciditv of the whole system ; and therefore give rea- 
son to conclude, that the retention of the menses accompa- 
nying them, is owing to a weaker action of the vessels of the 
uterus ; which therefore do not impel the blood into their 
extremities with a force sufficient to open these, and pour 
out blood by them. 

1000.] How it happens that at a certain period of life a 
flaccidity of the system arises in young women not ori- 
ginally affected with any such weakness- or laxity, and of 
which but a little time before, they had given no indication, 
may be difficult to explain ; but I would attempt it in this 
way. 

As a certain state of the ovaria in females, prepares and 
disposes them to the exercise of venery, about the very pe- 
riod at which the menses first appear, it is to be presumed, 
that the state of the ovaria and that of the uterine vessels 
are in some measure connected together ; and as generally 
symptoms of a change in the state of the former appear be- 
fore those of the latter, it may be inferred that the state of 
the ovaria has a great share in exciting the action of the 
uterine vessels and producing the menstrual flux. But ana- 

* This is a very extraordinary symptom, which has not hitherto been explained. It some- 
times accompanies every cessation of the uterine discharge, but frequently appears in the most 
violent degree, in pregnancy. In young women, the appetite for chalk, lime-rubbish, charcoal, 
and various absorbents, is the most prevalent. Stahl, and his followers, made great use of llii* 
circumstance in supporting their favorite opinion of the vis medicatrix naturae. 

+ These pains are not properly symptoms of the disease, but prognostics of the efforts nature 
makes to remove the disease; Tbey are symptoms of the vis meditattix. 



PRACTICE OF PHYSIC. 315 

logous to what happens in the male sex, it may be presum- 
ed, that in females a certain state of the genitals is neces- 
sary to give tone and tension to the whole system ; and. 
therefore that, if the stimulus arising from the genitals be 
wanting, the whole system may fall into a torpid and flac- 
cid state, and from thence the chlorosis and retention of the 
menses may arise. 

1001.] It appears tome, therefore, that the retention of 
the menses is to be referred to a certain state or affection of 
the ovaria : but what is precisely the nature of this affection, 
or what are the causes of it, I will not pretend to explain ; 
nor can I explain in what manner that primary cause of re- 
tention is to be removed. In this, therefore, as in many 
other cases, where we cannot assign the proximate cause 
of diseases, our indications of cure must be formed for ob- 
viating and removing the morbid effects or symptoms which 
appear. 

1002.] The effects, as has been said in 999, consist in a 
general flaccidity of the system, and consequently in a 
weaker action of the vessels of the uterus ; so that this de- 
bility may be considered as the more immediate cause of 
the retention. This therefore, is to be cured by restoring 
the tone of the system in general, and by exciting the ac- 
tion of the uterine vessels in particular. 

1003.] The tone of the system in general is to be restored 
by exercise, and in the beginning of the disease, by cold 
bathing. At the same time, tonic medicines* may be em- 
ployed ; and of these the chalybeatcs have been chiefly re- 
commended. 

1 004.] The action of the vessels of the uterus may be 
excited : 

1st, By determining the blood into them more copiously ; 
which is to be done by determining the blood into the de- 
scending aorta, by purging, by the exercise of walking, f 
by friction, and by warm bathing of the lower extremities. 
It is also probable that the blood may be determined more 
copiously into the hypogastric arteries which go to the ute- 
rus, by a compression of the iliacs ; but the trials of this 
kind hitherto made have seldom succeeded. 

* Forms of the tonic medicines have been given in some of the preceding notes. The elec- 
tviary in the note on article 962. is frequently Vised with success. In this case, we must not use 
astringent!, but tonics, and consequently only such tonics as are not astringents, at least in a high 
degree. The simple bitter tonics frequently answer where the symptoms are not severe. The 
Inrusum gentians compositum of the new London Pharmacopoeia is a good formula. The dose 
of it is two ounces iwice a-day, or oftencrit the stomach can bear it. 

Chalybeatcs are absolutely necessary if the disease withstands the use of bitters ; they may be 
in any of the forms mentioned in the preceding Q< 

+ Dancing is also a proper exercise iatbii di 



316 PRACTICE OF PHYSIC. 

1005.] 2dly, The action of the uterine vessels may be 
excited by stimulants applied to them. Thus those purga- 
tives which particularly stimulate the intestinum rectum,* 
may also prove stimulant to the uterine vessels connected 
with those of the rectum. The exercise of venery certain- 
ly proves a stimulus to the vessels of the uterus; and 
therefore may be useful when, with propriety, it can be 
employed. The various medicines recommended as sti- 
mulants of the uterine vessels, under the title of Emena- 
gogues, have never appeared to me to be effectual ; and I 
cannot perceive that any of them are possessed of a specific 
power in this respect. Mercury, as an universal stimulant, 
may act upon the uterus, but cannot be very safely em- 
ployed in chlorotic persons. One of the most powerful 
means of exciting the action of the vessels in every part of 
the system is, the electrical shock; and it has often been 
employed with success for exciting the vessels of the uterus. 

1006.] The remedies (1002 — 1005.) now mentioned, 
are those adapted to the retention of the menses ; and I am 
next to consider the case of suppression. In entering upon 
this, I must observe, that every interruption of the flux, 
after it has once taken place, is not to be considered as a 
case of suppression. For the flux, upon its first appear- 
ance, is not always immediately established in its regular 
course; and therefore, if an interruption happen soon after 
the first appearance, or even in the course of the first, or 
perhaps second year after, it may often be considered as a 
case of retention, especially when the disease appears with 
the symptoms peculiar to that state, 

♦ These stimulant purges are in general the drastic resins, as Scammony, Aloes, &c. Various 
formula; of them have been recommended in these cases ; the Piluli Rufi is commonly used 
with good effect. It may be given in the quantity of half a drachm, or, in strong constitutions, 
two scruples. It ought not to be repeated above twice a week ; and, in the intermediate days, 
we may employ the tonic medicines above mentioned. 

The Pilulae ecphracticae of the Edinburgh Pharmacopoeia is another very effectual medicine 
in these cases. Its dose is half a drachm twice a week, if we intend to purge briskly ; but, tar 
giving a smaller quantity, as ten, twelve, or fifteen grains once a-day, a constant stimulus is 
preserved, which some practitioners prefer. 

The following pills are also much recommended: 

R. Pil. Gummos, 

Aloes Socotorin. aa 3". 

Vin. Aloet. q. s. 

M. f. Massa in pilulas. 48. dividend. 

The dose is3 or 4 pills at bed time. ■ 

The tinctura sacra is also frequently used as a brisk purse in these cases ; its dose for this pur- 
pose must not be less than an ounce and a half in most habits ; but a strong constitution will re- 
quire two ounces or more. ' 

Other stimulants than purges have been employed in amenorrheca, as the Tinctura sabina 
composita of the new London Pharmacopoeia; its dose is thirty or forty dtops, in any suitable 
vehicle. The Tinctura myn hoe of the same Pharmacopoeia, in doses of twenty or thirty drops, 
is often recommended on the authority of Boerhaave. 



PRACTICE OF PHYSIC. 317 

1007.] Thpse which may be properly considered as cases 
of suppression, are such as occur after the flux has been 
for some time established in its regular course, and in 
which the interruption cannot be referred to the causes of 
retention (1001, 1002.) but must be imputed to some re- 
sistance in the extremities of the vessels of the uterus. Ac- 
cordingly, we often find the suppression induced by cold, 
fear, and other causes which may produce a constriction 
of these extreme vessels. Some physicians have supposed 
an obstructing lentor of the fluids to occasion the resistance 
now mentioned: but this is purely hypothetical, without 
any proper evidence of the fact ; and it is besides, from 
other considerations, improbable. 

1008.] There are indeed some cases of suppression that 
seem to depend upon a general debility of the system, and 
consequently of the vessels of the uterus. But in such cases, 
the suppression always appears as symptomatic of other 
affections, and is therefore not to be considered here. 

1009.] The idiopathic cases of suppression (1007.) sel- 
dom continue long without being attended with various 
symptoms or disorders in different parts of the body; very 
commonly arising from the blood which should have pass- 
ed by the uterus, being determined more copiously into 
other parts, and very often with such force as to produce 
hemorrhagies in these. Hence hemorrhagies from the nose, 
lungs, stomach, and other parts, have appeared in conse- 
quence of suppressed menses. Beside these, there are 
commonly hysteric and dyspeptic symptoms produced by 
the same cause ; and frequently colic pains, with a bound 
belly. 

1010.] In the idiopathic cases of suppression, (1007.) 
the indication of cure is to remove the constriction affect- 
ino 1 the extreme vessels of the uterus; and for this pm-pose 
the chief remedy is warm bathing applied to the region of 
the uterus. This, however, is not always effectual, and I 
do not know of any other remedy adapted to the indication. 
Besides this, we have perhaps no other means of removing 
the constriction in fault, but that of increasing the action 
and force of the vessels of the uterus, so as thereby to over- 
come the resistance or constriction of the extremities. This 
therefore is to be attempted by the same remedies in the 
case of suppression, as those prescribed in the cases of re- 
tention (1003. 1005.) The tonics, however, and cold- 
bathing (1003.) seem to be less properly adapted to the 



31 S PRACTICE OF PHYSIC. 

cases of suppression, and have appeared to me of ambi- 
guous effect.* 

101 1.] It commonly happens in the cases of suppression, 
that though the menses do not flow at their usual periods, 
there are often at those periods some marks of an effort 
having a tendency to produce the discharge. It is there- 
fore at those times especially when the efforts of the sys- 
tem are concurring, that we ought to employ the remedies 
for curing a suppression ; and it is commonly fruitless to 
employ them at other times, unless they be suchf as re- 
quire some continuance in their use to produce their effects. 

1012.] Nearly similar to the cases of suppression, are 
those cases in which the menses flow after long intervals, 
and in lesser quantity than usual ; and when these cases 
are attended with the disorders in the system (1009.) they 
are to be cured by the same remedies as the cases of entire 
suppression. 

1013.] It may be proper in this place to take notice of 
the desmenorrhea, or cases of menstruation in which the 
menses seem to flow with difficulty, and are accompanied 
with much pain in the back, loins, and lower belly. We 
impute this disorder partly to some weaker action of the 
vessels of the uterus, and partly, perhaps more especially, 
to a spasm of its extreme vessels. We bave commonly 
found the disease relieved by employing some of the reme- 
dies of suppression immediately before the approach of the 
period, and at the same time employing opiates. 



CHAPTER IX. 

OF SYMPTOMATIC HEMORRIIAGIES. 

1014.] T HAVE thought it very improper, in this work, 
A to treat of those morbid affections, that are al- 
most always symptomatic of other more primary diseases ; 
and this for several reasons, particularly because it intro- 
duces a great deal of confusion in directing practice, and 
leads physicians to employ palliative measures only. I 

* The Emenagogues enumerated in the note on article 1005. are more efficacious in these ca- 
ses than the tonics and chalybeates mentioned in the note., n for this rea on, that the 
suppression of the menses depends more on the consinciion, lian on a ) :\ity of the extreme ves- 
sels. Some cases, indeed, occur, where a lax habit i. the cau»c of suppression, but thev art 
rare : The physician ought to be attentive in discriminating such cases, because a liberal use of 
forcing emenagogues is always hur if ul in them ; they can only be relieved by tonics, and espe- 
cially by chalybeates. 

+ Viz. tonics or alterants. 



PRACTICE OF PHYSIC. " 31 9 

shall here, however, deviate a little from my general plan, 
to make some reflections upon symptomatic hemorrhagies. 
10J5.] The hemorrhagies of this kind that especially 
deserve our notice, are the Hematemesis, or Vomiting of 
Blood ; and the Hematuria, or the Voiding of Blood from 
the urinary passage. Upon these I am here to make some 
remarks ; because, though they are very generally symp- 
tomatic, it is possible they may be sometimes primary and 
idiopathic affections ; and because they have been treated 
of as primary diseases in almost every system of the prac- 
tice of physic. 



SECTION I. 

Of the Hematemesis, or Vomiting of Blood. 

1016.] I HAVE said above in 944, in what manner 
blood thrown out from the mouth may be known to pro- 
ceed from the stomach, and not from the lungs ; but it 
may be proper here to say more particularly, that this 
may be certainly known, when the blood is brought up 
manifestly by vomiting without any coughing ; when this 
vomiting has been preceded by some sense of weight, 
anxiety, and pain, in the region of the stomach ; when the 
blood brought up is of a black and grurnous appearance, 
and when it is manifestly mixed with other contents of the 
stomach ; we can seldom have any doubt of the source 
from whence the blood proceeds, and therefore of the ex- 
istence of the disease we treat of. 

1017.] We must allow it to be possible that a plethoric 
state of the body from general causes may be accompani- 
ed with causes of a peculiar determination and afflux of 
blood to the stomach, so as to occasion an hemorrhagy 
there, and thence a vomiting of blood ; and in such a case 
this appearance might be considered as a primary disease. 
But the history of diseases in the records of physic, afford 
little foundation for such a supposition ; and on the con- 
trary, the whole of the instances of a vomiting of blood 
which have been recorded, are pretty manifestly symptom- 
atic of a more primary affection. 

Of such symptomatic vomitings of blood, the chief in- 
stances are the following. 

1018.] One of the most frequent is that which appears 



320 PRACTICE OF PHYSIC. 

m consequence of a suppression of an evacuation of blood 
which had been for some time before established in another 
part of the body, particularly that of the menstrual flux in 
women. 

1019.] There are instances of a vomiting of blood hap- 
pening from the retention of the menses : but such instances 
are very uncommon ; as retention of the menses rarely 
happens in consequence of, or even with a plethoric state 
of the body; and as rarely does it produce that, or the 
hemorrhagy in question. 

There are instances of a vomiting of blood happening 
to pregnant women ; that might therefore also be imputed 
to the suppression of the menses, which happens to women 
in that state. There have indeed been more instances of 
this than of the former case ; but the latter are still very 
rare : for although the blood which used to flow monthly 
before impregnation, is, upon this taking place, retained, 
it is commonly so entirely employed in dilating the uterine 
vessels, and in the growth of the fetus that it is seldom 
found to produce a plethoric state of the body, requiring 
a vicarious outlet. 

The vomiting of blood, therefore, that is vicarious of 
the menstrual flux, is that which commonly and almost on- 
ly happens upon a suppression of that flux, after it had 
been for some time established. 

1 020.] When such a suppression happens, it may be sup- 
posed to operate by inducing a plethoric state of the whole 
body, and thereby occasioning hemorrhagy from other 
parts of it ; and hemorrhagies from many different parts 
of the body have been observed by physicians as occur- 
ring in consequence of the suppression we speak of. It is 
however the great variety of such hemorrhagies, that leads 
me to think, that with the plethoric state of the Avhole body 
there must be always some peculiar circumstances in the 
part from which the blood flows, that determines its afflux 
to that particular, often singularly odd, part ; and there- 
fore, that such hemorrhagies may from these circumstances 
occur without any considerable plethora at the same time 
prevailing in the whole system. 

1021.] It is to be observed, that if we are to expect an 
hemorrhagy in eonsequenee of a suppression of the menses 
inducing a plethoric state of the system, we should expect 
especially an hemoptysis, or hemorrhagy from the lungs, 
as a plethora might be expected to show its effects especi- 



TRACTICE OF PHYSIC. 3 2l 

ally there; and accordingly, upon occasion of suppressed 
menses, that hemorrhagy occurs more frequently than any 
other : but even this, when it does happen, neither in its 
circumstances nor its consequences, leads us to suppose, 
that at the same time any considerable or dangerous plethora 
prevails in the body. 

1022.] These considerations (in 1020. 1021.) will, I ap- 
prehend, apply to our present subject ; a«nd I would there- 
fore alledge, that a hematemesis may perhaps depend upon 
particular circumstances of the stomach determining an af- 
flux of blood to that organ, and may therefore occur with- 
out any considerable or dangerous plethora prevailing in the 
system. What are the circumstances of the stomach, 
which upon the occasion mentioned, may determine an af- 
flux of blood to it, I cannot certainly or clearly explain ; 
but presume that it depends upon the connection and con- 
sent which we know to subsist between the uterus and the 
whole of the alimentary canal, and especially that principal 
part of it, the stomach. 

. 1023.] From these reflections, we may, I think draw the 
following conclusions : 

I. That the hematemesis we speak of is hardly ever a 
dangerous disease. 

II. That it will hardly ever require the remedies suited to 
the cure of active hemorrhagy ; and at least that it will re- 
quire these only in those unusual cases in which there ap- 
pear strong marks of a general plethora, and in which the 
vomiting of blood appears to be considerably active, very 
profuse, and frequently recurring. 

III. That a vomiting of blood from suppressed menses, 
ought seldom to prevent the use of these remedies of ame- 
norrhoea, which might be improper in the case of an active 
idiopathic hemorrhagy. 

1024.] Another case of symptomatic hematemesis quite 
analagous to that already mentioned, is the hematemesis 
following, and seemingly depending upon, the suppression 
of an hemorrhoidal flux, which had been established and 
frequent for some time before. 

This may perhaps be explained by a general plethoric 
state induced by such a suppression ; and indeed some de- 
gree of a plethoric state must in such a case be supposed to 
take place ; but that supposition alone will not explain the 
whole of the case ; for a general plethora would lead us to 
expect an hemoptysis (1021.) rather than an hematemesis ; 

3t 



322 PRACTICE OF PHYSIC. 

and there is therefore something still wanting, as in the 
former case, to explain the particular determination to the 
stomach. 

Whether such an explanation can he got from the con- 
nexion between the different parts of the sanguiferous ves- 
sels of the alimentary canal, or from the connexion of the 
whole of these vessels with the vena portarum, I shall not 
venture to determine. But in the mean time I imagine, 
that the explanation required is rather to be obtained from 
that connexion of the stomach with the hemorrhoidal af- 
fection that I have taken notice of in 945. 

1025.] How we may explain the hematemesis occasioned 
by a suppression of the hemorriiois, the considerations in 
1020, 1021, will apply here as in the analogous case of he- 
matemesis from suppressed menses ; and will therefore al- 
low us also to conclude here, that the disease we now treat 
of will seldom be dangerous, and will seldom require the 
same remedies that idiopathic and active hemorrhagy does. 

1026.] The cases of hematemesis already mentioned, 
may be properly supposed to be hemorrhagies of the arte- 
rial kind ; but it is probable that the stomach is also liable 
to hemorrhagies of the venous kind (76 7.) 

In the records of physic there are many instances of vo- 
miting blood, which were accompanied with a tumefied 
spleen, which had compressed the vas breve, and thereby 
prevented the free return of venous blood from the stomach. 
How such an interruption of the venous blood may occa- 
sion an hemorrhagy from either the extremities of the veins 
themselves, or from the extremities of their correspondent 
arteries, we have explained above in 768 ; and the histories 
of tumefied spleens compressing the vasa brevia, afford an 
excellent illustration and confirmation of our doctrine on 
that subject, and render it sufficiently probable that vomit- 
ings of blood often arise from such a cause. 

1027.] It is also possible, that an obstruction of the liver 
resisting the free motion of the blood in the vena portarum, 
may sometimes interrupt the free return of the venous blood 
from the vessels of the stomach, and thereby occasion a vo« 
miting of blood ; but the instances of this are neither so 
frequent nor so clearly explained as those of the former case. 

1028.] Besides these cases depending on the state of the*, 
liver or spleen, it is very probable that other hemorrhagies 
of the stomach are frequently of the venous kind. 

The disease named by Sauvages, Melaena, and by other 



PRACTICE OF PHYSIC. 

writers commonly termed the Morbus Niger (7*7 1 .) consist- 
ing ip an evacuation either by vomiting or by stool, and 
so :i,;tinies in both ways, of a black and grumous blood, can 
hardly be otherwise occasioned, than by a venous hemor- 
rliagy from some part of the internal surface of the alimen- 
tary canal. 

It is, indeed, possible, that the bile may sometimes put 
on a black and viscid appearance, and give a real founda- 
tion for the appellation of an Atra Bilis : but it is certain, 
that instances of this are very rare ; and it is highlv proba- 
ble that . hat gave occasion to the notion of an atra inlis among 
the ancients, was truly the appearance of blood poured into 
the alimentary canal in the manner I have mentioned ; and 
Which appearance, we know, the blood always puts on 
when it has stagnated there for any length of lime. 1 sup- 
pose it is now generally thought, that Boer. laave's notion of 
such a matter existing in the mass of blood, is without any 
foundation ; whilst, by dissections in modern times, it ap- 
pears very clearly, that the morbus niger presenting such 
an appearance of blood, always depends upon the effusion 
and stagnation I have mentioned. 

1029. J From this account of the melaena it will appear 
that vomiting of blood may arise iu consequence of bio ^d 
being poured out in the manner 1 have mentioned, either 
into the cavity of the stomach itself, or into the superior 
portions of the intestines, from whence matters often pass 
into the stomach. 

1030.] Both in the case of the mclama, and in the ana- 
logous cases from affections of the spleen or liver, it yvilj 
appear, that the vomitings of blood occurring must be 
considered as symptomatic affections, not at all to be treat- 
ed as a primary active hemorrhagy, but by remedies, if 
any such be known, that may resolve the primary obstruc- 
tions.* 

• This is doubtless the most rational practice, namely, to resolve the obttruction which has oc- 
casioned i he blood to be thrown or driven to the intestines. To discover this primary obstruc- 
tion is, however, sometimes extremely difficult ; and, even when it is discovered, it is fre- 
quently not easily resolved; in such cases, therefore, we must use the general remedies for re- 
moving the plethora, except laxatives, the operations ol which, in general, derive the llmds to 
the intestine* Sweating is perhaps the best general evacuation tor determining the fluids 
Jro.n the intestines; but its u-.e ought to he p>eceded by bleed ng ; and it ought not, in these 
cases, to be excitea by nauseating doses of emetics, as th ?SC i.ioiiuce tne same eflect 
tivc-sj we must therefore have recourse io the lighi aromatic-, ss^e, mint, balm, wine whey, 
tic. Camphor and opium arc also proper sudoutus in these casts They may be eiv.n toge- 
ther, a* in the lollowm; b'.lus: 

R. Camphor, gr. vi. 
Spir. vini gutt. x. 
Opii pur. gr. u 



324 PRACTICE OF Pnisiu. 

1031.] I believe I have now mentioned almost the whole 
of the causes producing an hematemesis ; and certainly the 
causes mentioned, arc those which most commonly give 
occasion to that symptom. Possibly, however there may 
be some other causes of it, such as that singular one men- 
tioned by Sauvage of an aneurism of the aorta bursting in- 
to the stomach; and it is possible, that some diseases of 
other contiguous parts, which have become closely adher- 
ing to the stomach, may sometimes, by a rupture into the 
cavity of t.ie stomach, pour blood into it, which is after- 
wards rejected by vomiting. It is possible also, that ab- 
scesses and ulcerations of the stomach itself, may some- 

Conf. card. 3ss. vel q. s. 
M. f. bolus. 

Some practitioners have recommended large quantities of spermaceti in cases of hemate- 
mesis, and not without reason. it ;nay he given in emulsioni, with yolks of eggs, or in an 
electuary. 1 shall therefore add a formula ot each. 

R. Spermat. cet. Bss. 
Vitel. ovi q. s. 

Tere in mortar, mormoreo, et adde 
Aq. font. ivii. 
Syr. simpl. §i. 
M. f. Emuls. 

The dose of this emulsion is two or three table-spoonfuls every three hours. 

R. Spermat. cet. §i. 
Conserv. rosar. §ii. 
Syr. Simp. Si- 
M. f. Elect. 

The dose of this electuary is a tea-spoonful or two every two or three hours. 

If the hematemesis be violent we must have recourse to some of the styptics and astringents 
mentioned before in the cure of the hemorrhagy in general, as alum, catechu, kino, &c. of 
which 1 shal'lsubjoin some formula. 

R. Alum. ust. gr. iii. 
Kino 9ss. 
M. f. Pulvis. 

This powder may be repeated every two hours, and three table-spoonfuls of the tincture of 
roses may be given to wash it down. 

Theelectuarium japonicum of the Edinburgh Parmacopceia is well calculated for these cases j 
its dose is a drachm and a half or two drachms. 

The extract of logwood is sometimes used in these cases with considerable success. It may 
either be given alone in doses of a scruple each every three hours, or joined with alum, as in 
the following fotmula : 

R. Extract, lign. Campechens. Bss. 
Alum. ust. gr. iii. 
M. f. pulvis. 

This powder may tie repeated every three hours ; drinking after it three table-spoonfuls of 
the tincture of roses ; or a tea-cupful of cold water, with twenty or thirty drops of the aciduin 
vitriolicum dilutum, or as much as sufficient to give an agreeable acidity. 

All these styptics and astringents are apt to produce costiveness, which much be removed b7 
emollient glysters, as laxative medicines are, for the reasons above mentioned, generally hurt- 
ful in these cases. 

The young practitioner must not trust to these medicines for completely curing a hemorrhage 
from the intestines; they are only palliatives, and are of no other use than to check the violence 
of the discharge until the true cause of the disease be discovered; and the discovery of this 
cause must be left to the sagacity ot the physician. 



PRACTICE OF PHYSIC. 325 

times pour blood into its cavity to be thrown up by vo- 
miting. 

I did not think it necessary, among the symptomatic vo- 
mitings of blood, to enumerate those from external vio- 
lence, nor, what is analogous to it, that which arises from 
violent straining to vomit; which last, however, is much 
more rare than might be expected. In either ot these cases 
the nature of the disease cannot be doubtful, and the ma- 
nagement of it will be readily understood from what has 
been delivered above with respect to moderating and res- 
training hemorrhagy in general. 



SECTION II. 



Of the Hematuria, or the Voiding of Blood from 
the Urinary Passage. 

1032.] IT is alledged, that an hematuria has occurred 
without any other symptom of an affection of the kidneys 
or urinary passages being present at the same time; and as 
this happened to plethoric persons, and recurred at fixed 
periods, such a case has been supposed to be an instance 
of idiopathic hematuria, and of the nature of those active 
hemorrhagies I have treated of before. 

1033.] I cannot positively deny the existence of such a 
case; but must observe, that there are very few instances 
of such upon the records of physic ; that none have ever 
occurred to my observation, or to that of my friends ; and 
that the observations adduced may be fallacious, as I have 
frequently observed an hematuria without symptoms of 
other affection of the kidney or urinary passages being, for 
the time, present; whilst, however, fits of a nephralgia 
calculosa having, before, or soon after, happened, ren- 
dered it to me sufficiently probable, that the hematuria 
was owing to a wound made by a stone present in some 
part of the urinary passages. 

1034.] The existence of an idiopathic hematuria is fur- 
ther improbable, as a general plethora is more likely to 
produce an hemoptysis (1021.) and as we do not well 
know of any circumstance which might determine more 
particularly to the kidneys. An idiopathic hematuria, there- 
fore, must certainly be a rare occurrence ; and instances of 
symptomatic affections of the same kind are very frequent. 



526 PRACTICE OF PHYSIC. 

1035.] One of the most frequent is, that hematuria 
which attends the nephralgia caleulosa, and seems mani- 
festly to be owing to a stone wounding the internal surface 
of the pelvis of the kidney or of the ureter. In such cases, 
the blood discharged with the urine is sometimes of a 
pretty florid color, but for the most part is of a dark hue: 
the whole of it is sometimes diffused or dissolved, and 
therefore entirely suspended in the urine ; but if it is in 
any large quantity, a portion of it is deposited to the bot- 
tom of the vessel containing the voided blood and urine. 
On different occasions, the blood voided puts on different 
appearances. If the blood poured out in the kidney has 
happened to stagnate for some time in the ureters or blad- 
der, it is sometimes coagulated, and the coagulated partis 
afterwards broken down into a grumous mass of a black or 
dark color, and therefore gives the same color to the urine 
voided ; or if the quantity of broken down blood is small, 
it gives only a brownish urine resembling coffee. It some- 
times also happens, that the blood stagnating and coagu- 
lating in the ureters, takes the form of these vessels, and 
is therefore, voided under the appearance of a worm ; and 
if the coagulated blood happens to have, as it may some- 
ti es, have, the gluten separated from the red globules, these 
worm-like appearances have their external surface whitish, 
and the whole seemingly forming a tube containing a red 
liquor. 1 have sometimes observed the blood which had 
seemingly been coagulated in the ureter, come away in 
an almost dry state, resembling the half-burnt wick of a 
candle.* 

1036.] These are the several appearances of the blood 
voided in the hematuria caleulosa, when it proceeds espe- 
cially from the kidneys or ureter; and many of the same 
appearances are observed when the blood proceeds only 
from the bladder when a stone is lodged there; but the 
attending symptoms will commonly point out the different 
seat of the disease. 

In one case, when a quantity of blood from the kidney 
or ureter is coagulated in the bladder, and is therefore dif- 

* In genera!, the blood is coagulated and grumous ; hence the urine deposits a dark brown 
substance somewhat re^emblm',' coffee giojmis- 

As the grurao j> blood is specifically Heavier than the urine, it falls to the bottom of the blad- 
der, and is consequently voided in greater quantity in the beginning t ian towards ihe end of 
making water, the u.ine that comes off firs! being very Jeep colu.ed and muddy, but becom- 
ing, while it flows, gradually more transparent and pure, until at last n is per c ectly of a natural 
appearance. The patient generally men lions this circumstance in describing his complaints, 
with this addition, that he has in the beginning some difficulty o' making waiir, but that this 
difficulty decreases in proportion as the urine becomes more tian.parent. 



PRACTICE OF PHYSIC. S 11 

ficultly thrown out from this, the pain and uneasiness on 
such an occasion may appear chiefly to he in the bladder, 
though it contains no stone; but the antecedent symptoms 
will commonly discover the nature of the disease. 

10:37. J Jn any of the cases of the hematuria calculosa, 
it will hardly be necessary to employ the remedies suited 
to an active hemorrhagy. It will be proper only to em- 
ploy the regimen fit for moderating hemorrhagy in general, 
and particularly here to avoid every thing or" circumstance 
that might irritate the kidneys or ureters. Of such cases 
of irritation there is none more frequent or more consider- 
able than the presence of hardened faces in the colon; 
and these therefore are to be frequently removed by the 
frequent use of gentle laxatives.* 

1033.] The hematuria calculosaf may be properly con- 
sidered as a case of the hematuria violenta: and therefore 
I subjoin to that the other instances of hematuria from ex- 
ternal violence ; such as that from external contusion on 
the region of the kidney,! and that from the violence or 
long continued exercise of the muscles incumbent on the 
kidneys. An instance of the latter cause occurs especial- 
ly in riding. § 

1039. J It may also be considered as a case of the hema- 
turia violenta, when the disease occurs in consequence of 
the taking in of certain acrid substances, which pass again 
especially by the urinary passages ; and by inflaming and 
swelling the neck of the bladder, bring on a rupture of the 
over-distended blood-vessels, and give occasion to a bloody 
urine. The most noted instance of this is in the effect of 
cantharides in a certain quantity, any way introduced into 
the body. And possibly some other acrids may have the 
same effect. |j 

* Clysters are preferable to purgatives in these cases, because they are less stimulating ; and 
thceiini.lientgiysteu arc preferable to all ntheis, for their only intention is to soften the barr- 
elled toeces. The only purgatives to be used are those 01 the mildest kind, as manna, oil, 1 . 
*:>'. The intention 01 purgatives, in these cases, is only to remove the hardened faxes; and 
this intention can often be sufficiently answered by a proper choice of food, as broths, csj. e 
ly those made with bailey and )oung animal flesh; barley gruel, with prunes boiled in it : slew- 
ed 1 mlive. I. mice, ar.-i oilier oleraceous dishes. 
+ The hematuria calculosa being symptomatic, can only be cured by removing the cause ; it 
relieved by demulcents, aslints'eed tea, decoliuii ot marsh mallow-, 
t 'if gum Arabic, thick baile; 
} The hematuria proceeding iiom a contusion of the region of the kidneys requires general 
and topical bleeding, with purees, and an attention to the antiphlogistic regimen. i>cme 1 
titionert recommend the warm balsams in the^e cases; but, on account 01 their beating quality, 
their use is somewhat doubtful. Nine isnot always admissible, on account of us iirnating the 
powerful antiphlogistic ; and, ft it is used in these cases, it most be well di- 
me mil' Uagiui us drinks aieabsoiute.y necessary, ami ought to be used plentifully. 
nly method Of treating this kind of hematuria is by rest. /\ person subject to it ought 
to lido. 
(I I hematuria is cured by evacuating the acid substance, and by the use of the 

mucilaginous drinks before mentioned. The acrid substance may be evacuated by anttphlu- 
, or by the milder diuretics, as nitre, decoctions of p*riiey roots, cream of ta;u:, 



328 PRACTICE OF PHYSIC. 

1040.] Beside these most frequent instances of hematuria, 
which cannot be considered as idiopathic hemorrhagies, 
there are some other instances of hematuria mentioned by 
authors, that are still however manifestly symptomatic ; 
such as a discharge of blood from the urinary passages, in 
consequence of a suppression of either the menstrual or he- 
morrhoidal flux. These may be considered as analogous to 
the hematemesis produced by the like causes ; and the se- 
veral reflections made above on that subject, will I think, 
apply here, and particularly the conclusions formed in 
1023. Instances, however, of either of these cases, and 
especially of the first, have been extremely rare. 

1041.] Of such symptomatic hematuria there is however 
one instance deserving notice ; and that is, when a sup- 
pression of the hemorrhoidal flux, either by a communica- 
tion of vessels, or merely by the vicinity of parts, occa- 
sions a determination of the blood into the vessels of the 
neck of the bladder, which in consequence of a rixis or 
anastomosis, pour out blood to be voided either with or 
without urine. This case is what has been named the 
Hemorrhoides Vesicae ; and with some propriety, when it 
is manifestly an evacuation vicarious of what had before 
been usually made from the rectum. With respect to the 
management of the hemorrhoides vesicas, I Mould apply 
the whole of the doctrines that I have delivered above, with 
respect to the cure of the proper hemorrhoidal affection.* 

1042.] There remains still to be mentioned one other in- 
stance of symptomatic hematuria, Avhich is that which hap- 
pens in the case of confluent and putrid small-pox, as well 
as in several other instances of putrid diseases. The 
blood, in such cases, may be presumed to come from the 
kidneys ; and I apprehend that it comes from thence in con- 
sequence of that fluidity which is always produced in the 
blood approaching to a putrid state. Such hematuria, 

whey, fcc. The action of cantharides on the urinary passages is not well explained. We can 
scarcely believe that any part of the cantharides is absorbed from the blistering plaister; yet us 
effects are the same with those produced by taking the cantharides internally. The strangury,, 
and its concomitant symptoms, may be relieved bv large and plentiful dilution, and a fiee use- 
of the mucilaginous drinks. Camphor has been thought to have some specific quality in pre- 
venting and curing the strangury produced by blisters, and experience warrants the con'clusiou s. 
especially if the camphor is joined with opium, as in the following formula : 

Be. Camphor, gr. vi. 
Spir. vini gutt. x. 
Opii puri gr. i. 
Conserv. rosar. 3i- 
M. f. bolus. 

» Articles 946. et sequent. 



PRACTICE OF PHYSIC. 329 

therefore, is not to be considered as a symptom of any af- 
fection of the kidneys, but merely as a mark of the pu- 
trescent state of the blood. 

1043.] In certain diseases the urine is discharged of such 
a deep red cofer, as to give a suspicion of its being tinged 
by blood present in it ; and this has given occasion to Sau- 
vages, amongst the other species of hematuria, to mark the 
hematuria spuria, and the hematuria lateritia ; both of 
which, however, he supposes to be without any blood pre- 
sent in the urine. In many cases it is of importance, in 
ascertaining the nature of the disease, to determine whether 
the red color of urine be from blood present in it, or from 
a certain state of the salts and oils which are always in great- 
er or lesser proportion constituent parts of the urine ; and 
the question may be commonly determined by the follow- 
ing considerations. 

. It has been observed above, that when any considerable 
quantity of blood is voided with the urine, there is always 
a portion of it deposited at the bottom of the vessel con- 
taining the voided blood and urine : and in such a case there 
will be no doubt in attributing the color of the urine float- 
ing above to some part of the blood diffused in it. The 
question, therefore, with respect to the presence of blood 
in the urine can only occur when no such deposition as I 
have mentioned appears ; and when the blood that may be 
supposed to be present is dissolved or diffused, and there- 
fore entirely suspended in the urine. In this case the pre- 
sence of the blood may be commonly known, 1st, By the 
color, which blood gives, different from any urine without 
blood that I have ever seen ; and I think a little experience 
will enable most persons to make this distinction. 2dly, By 
this, that the presence of blood always diminishes the trans- 
parency of the urine with which it is mixed ; and it is very 
seldom that urine, though very high colored, loses its 
transparency ; at least this hardly ever appears, if the urine 
is examined when recently voided. 3dly, When urine has 
blood mixed with it, it tinges a piece of linen dipped into it 
with a red color, which the highest colored urine without 
blood, never does. 4thly, High colored urine without 
blood, upon cooling, and remaining at rest in a vessel, al- 
most always deposits a lateritious sediment ; and if upon 
any occasion bloody urine should deposit a sediment that 
may be of a portion of the blood formerly diffused in it, 
the difference, however, may be discerned bv this, that the 

2u 



S30 PRACTICE OF PHYSIC. 

sediment deposited by urine without blood, upon the urine's- 
being again heated, will be entirely redissolved, which will 
not happen to any sediment from blood. Lastly, we know 
no state of urine without blood, which shews any portion of 
it, coagulable by a heat equal to that of boiling water ; but 
blood diffused in urine is still coagulable by such a heat j 
and by this test, therefore, the presence of blood in urine 
may be commonly ascertained. 



BOOK V. 

OF PROFLUVIA, OR FLUXES, WITH 
PYREXIA. 

1044.] TT'ORMER nosologists have established a class of 
.17 diseases under the title of Fluxes, or Proflu- 
via ; but as in this class they have brought together a great 
number of diseases, which have nothing in common, ex- 
cepting the single circumstance of an increased discharge 
of fluids, and which also are, in other respects, very dif- 
ferent from one another ; I have avoided so improper an ar- 
rangement, and have distributed most of the diseases com- 
prehended in such a class by the nosologists, into places 
more natural and proper for them.* I have, indeed, still 
employed here the general title ; but I confine it to such 
fluxes only as are constantly attended with pyrexia, and 
which therefore necessarily belong to the class of diseases of 
which I am now treating. 

Of the fluxes which may be considered as being very 
constantly febrile diseases, there are only two, the catarrh 
and dysentery ; and of these therefore, I now proceed to treat. 



CHAPTER I. 

OF THE CATARRH. 

1045.] nr^HE catarrh is an increased excretion of um_ 
X cus from the mucous membrane of the nose 
fauces, and bronchia?, attended with pyrexia. 

* Sauvages enumerates no less than thirty-six genera of fluxes, each of which are subdivided 
into numerous species. Vogel has forty five genera, under the title of Profluvia. most of whx li 
ase extremely different from each, other in their essential qualities. 



PRACTICE OF PHYSIC. 331 

Practical writers and nosologists have distinguished the 
disease by different appellations, according as it happens 
to affect those different parts of the mucous membrane, the 
one part more or less than the other ; But I am of opinion, 
that the disease, although affecting different parts, is al- 
ways of the same nature, and proceeds from the same cause. 
Very commonly, indeed, those different parts are affected 
at the same time ; and therefore there can be little room for 
the distinction mentioned. 

The disease has been frequently treated of under the title 
of Tussis, or Cough ; and a cough, indeed, always at- 
tends the chief form of catarrh, that is, the increased ex- 
cretion from the bronchiae : but a cough is so often a symp- 
tom of many other affections, which are very different 
from one another, that it is improperly employed as a ge- 
neric title. 

1046.] The remote cause of catarrh is most commonly 
cold applied to the body. This application of cold pro- 
ducing catarrh, can in many cases be distinctly observed ; 
and I believe it would always be so, were men acquaint- 
ed with, and attentive to, the circumstances which deter- 
mine cold to act upon the body. (See 94 — 96.) 

From the same paragraphs we may learn what in some 
persons gives a predisposition to catarrh. 

1047.] The disease, of which I am now to treat, gene- 
Tally begins with some difficulty of breathing through the 
nose, and with a sense of some fulness stopping up that pas- 
sage. This is also often attended with some dull pain and a 
sense of weight in the forehead, as well as some stiffness in 
the motion of the eyes. These feelings, sometimes at their 
very first beginning, and always soon after, are attended 
with the distillation from the nose ; and sometimes from the 
eyes, of a thin fluid, which is often found to be somewhat 
acrid, both by its taste, and by its fretting the parts over 
which it passes. 

1048.] These symptoms constitute the coryza and gra- 
vedo of medical authors, and are commonly attended with 
a sense of lassitude over the whole body. Sometimes cold 
shiverings are felt, at least the body is more sensible than 
usual to the coldness of the air ; and with all this the pulse 
becomes, especially in the evenings, more frequent than 
ordinary. 

1 049^] These symptoms seldom continue long before they 
*ire accompanied with some hoarseness, and a sense of 



332 PRACTICE OF PHYSIC. 

roughness and soreness in the tnichea, and with some diffi- 
culty of breathing, attributed to a sense of straitness of 
the chest, and attended with a cough, which seems to arise 
from some irritation felt at the glottis. The cough is gene- 
rally at first dr\*, occasioning pains about the chest, and 
more especially in the breast. Sometimes, together with 
these symptoms, pains resembling those of the rheumatism 
are felt in several parts of the body, particularly about the 
neck and head. While these symptoms take place, the ap- 
petite is impaired, some thirst arises, and a general lassi- 
tude is felt over all the body. 

1050.] These symptoms (1041. — 1049.) mark the vio- 
lence and height of the disease ; which, however, does not 
commonly continue long. By degrees the cough becomes 
attended with a copious excretion of mucus ; which is at 
first thin, but gradually becoming thicker, is brought up 
with less frequent and less laborious coughing. The hoarse- 
ness and soreness of the trachea likewise going off, the fe- 
brile symptoms abating, the cough becoming less frequent, 
and with less expectoration, the disease soon after ceases 
altogether. 

1051.] Such is generally the course of this disease, which 
is commonly neither tedious nor dangerous ; but, upon 
some occasions, it is in both respects otherwise. A person 
affected with catarrh seems to be more than usually liable 
to be affected by cold air ; and in that condition, if expos- 
ed to cold, the disease, which seemed to be yielding, is 
often brought back with greater violence than before ; and 
is rendered not only more tedious than otherwise it Mould 
have been, but also more dangerous by the supervening of 
other diseases. 

1052.] Some degree of the cynancbe tonsillaris often ac- 
companies the catarrh ; and, when the latter is aggravated 
by a fresh application of cold, the cynancbe also becomes 
more violent and dangerous, in consequence of the cough 
which is present at the same time. 

1053.] When a catarrh has been occasioned by a violent 
cause ; when it has been aggravated by improper manage- 
ment ; and especially when it has been rendered more vio- 
lent by fresh and repeated applications of cold, it often 
passes into a pneumonic inflammation attended with the ut- 
most danger. 

1054.] Unless, however, such accidents as those of 1051. 
— 1053, happen, a catarrh, in sound persons not far ad- 



PRACTICE OF PHYSIC. 333 

vanced in hfe, is, I think, always a slight disease, and at- 
tended with little danger. But, in persons of a phthisical 
disposition, a catarrh may readily produce an hemoptysis, 
or perhaps form tubercles in the lungs ; and more certainly, 
in persons who have tubercles already formed in the lungs, 
an accidental catarrh may occasion the inflammation of these 
tubercles, and in consequence produce a phthisis pulmonalis. 

1055.] In elderly persons, a catarrh sometimes proves a 
dangerous disease. Many persons, as they advance in life, 
and especially after they have arrived at old age, have the 
natural mucus of the lungs poured out in greater quantity, 
and consequently requiring a frequent expectoration. If 
therefore a catarrh happen to such persons, and increase 
the influx of fluids to the lungs, with some degree of in- 
flammation, it may produce the peripneumonia notha, 
which in such cases is very often fatal. (See 376. 382). 

1056.] The proximate cause of catarrh seems to be an 
increased afflux of fluids to the mucous membrane of the 
nose, fauces and bronchia?, along with some degree of in- 
flammation affecting these parts. The latter circumstance 
is confirmed by this, that in the case of catarrh, the blood 
drawn from a vein commonly exhibits the same inflamma- 
tory crust which appears in the case of phlegmasia;. 

1057.] The application of cold which occasions a ca- 
tarrh, probably operates by diminishing the perspiration 
usually made by the skin, and which is therefore determin- 
ed to the mucus membrane of the parts above mentioned. 
As apart of the weight which the body daily loses by insen- 
sible evacuation, is owing to an exhalation from the lungs, 
there is probably a connection between this exhalation and 
the cutaneous perspiration, so that the one may be increas- 
ed in proportion as the other is diminished: And therefore 
we may understand how the diminution of cutaneous per- 
spiration, in consequence of the application of cold, may 
increase the afflux of fluids to the lungs, and thereby pro- 
duce a catarrh. 

1058.] There are some observations made by Dr. 
James Keil which may seem to render this matter doubt- 
ful ; but there is a fallacy in his observations. The evi- 
dent effects of cold in producing coryza, leave, the matter 
in general without doubt; and there are several other cir- 
cumstances which show a connection between the lungs and 
the surface of the bod v. 

1059.] Whether, from the suppression of perspiration, 



331- PRACTICE OF PHYSIC. 

a catarrh be produced merely by an increased afflux of 
fluids, or whether the matter of perspiration be at the same 
time determined to the mucous glands, and there excite a 
particular irritation, may be uncertain; but the latter sup- 
position is sufficiently probable. 

1060.] Although, in the case of a common catarrh, 
which is in many instances sporadic, it may be doubtful 
whether any morbific matter be applied to the mucous 
glands; it is, however, certain, that the symptoms of 
catarrh do frequently depend upon such a matter being 
applied to these glands ; as appears from the case of 
measles, chin-cough, and especially from the frequent oc- 
currence of contagious and epidemical catarrh. 

1061.] The mention of this last leads me to observe, 
that there are two species of catarrh, as I have marked in 
my Synopsis of Nosology. One of these, as I suppose, 
is produced by cold alone, as has been explained above ; 
and the other seems manifestly to be produced by a speci- 
fic contagion. 

Of such contagious catarrhs,* I have pointed out in the 
Synopsis many instances occurring from the 14th century 
down to the present day. In all these instances the pheno- 
mena have been much the same ; and the disease has al- 
ways been particularly remarkable in this, that it has been 
the most widely and generally spreading epidemic known. 
It has seldom appeared in any one countrv of Europe, 
without appearing successively in every other part of it ; 
and in some instances, it has been even transferred to Ame- 
rica, and has been spread over that continent, so far as we 
have had opportunities of being informed. 

1062.] The catarrh from contagion appears with nearly 
the same symptoms as those mentioned (1047 — 1049.) It 
seems often to come on in consequence of the application 
of cold. It comes on with more cold shivering than the 
catarrh arising from cold alone, and sooner shows febrile 
symptoms, and these likewise in a more considerable de- 
gree. Accordingly, it more speedily runs its course, which 
is commonly finished in a few days. It sometimes termi- 
nates by a spontaneous sweat ; and this in some persons, 
produces a miliary eruption. It is, however, the febrile 
state of this disease especially, that is finished in a few 
days ; for the cough, and other catarrhal symptoms, do 
frequently continue longer ; and often, when they appear 

* These epidemical catarrlii have been lately termed Influenzal. 



PRACTICE OF PHYSIC. 335 

to be going off, they are renewed by any fresh application 
of cold. 

1063.] Considering the number of persons who are af- 
fected with catarrh, of either the one species or the other, 
and escape from it quickly Avithout any hurt, it may be al- 
lowed to be a disease very free from danger; but it is not 
always to be considered as such; for in some persons it is 
accompanied with pneumonic inflammation. In the phthi- 
sically disposed, it often accelerates the coming on of 
phthisis ; and in elderly persons, it frequently proves fa- 
tal in the manner explained above, (1053. and 1055.) 

1064.] The cure of catarrh is nearly the same, whether 
it proceed from cold or contagion ; with this difference, 
that in the latter case, remedies are commonly more neces- 
sary that in the former. 

In the cases of a moderate disease, it is commonly suf- 
ficient to avoid cold, and to abstain from animal food for 
some days ;* or perhaps to lie a-bed, and, by taking fre- 
quently of some mild and diluent drink a little warmed, to 
promote a very gentle sweat ; and after these to take care 
to return very gradually only, to the use of the free air. 

1065.] When the disease is more violent, not only the 
antiphlogistic regimen must be exactly observed, but va- 
rious remedies also become necessary. 

To take off the phlogistic diathesis which always attends 
this disease, blood-letting, in a larger or smaller quantity, 
and repeated according as the symptoms shall require, is 
the proper remedy. 

For restoring the determination of the fluids to the sur- 
face of the body,f and at the same time for expeding the 
secretion of mucus in the lungs, which may take off the 
inflammation of its membrane, vomiting is the most effec- 
tual means. 

* Perhaps an abstinence from all food would accelerate the cure : The mucilaginous drinks 
ought to be taken in considerable quantities, and they are somewhat nutritive. 

+ The means of producing a gentle and continued perspiration have been mentioned in a 

former note. In catarrh, however, the use of the warmer sudonfics seems most effectual. 

The elixir paregoricum, diluted with whey, especially whey made with the dulcified spirit of 

■ >i singular use , but it ought not to be given if there is a considerable degree ot pt.lo- 

ihesis. In this case, a spoonful of the following solution may be giten every two ur 

Ihree hours, ibl a sweat breaks out: 

ft. Tart. emet. gr. ii. 
Aq. font. §vi. 
Syr. Althreat §ii. 
M. 

1 1 will be necessary for the patient to chew occasionally some mucilaginous demulcent, as tx 

liquorice, fc'e. or to take a tea-spounlul ol equal p.irts ol -al and honey, in order to 

prevent the sharp matter from irriiai.ng the fauces. The Elect. Pectorale of the Edinburgh 

icopoeia not only relieves the tickling, hut tends to jnoduc«a ;alutarj «uaph«re»b , iu 

■ ibe viae ot a nutmeg three or four tiiu«s a-day. 



336 PRACTICE OF PHYSIC. 

- For the latter purpose, it has been supposed, that squills, 
gum ammoniac,* the volatile alkali, and some other medi- 
cines, might be useful : but their efficacy has never ap- 
peared to me to be considerable ; and, if squills have ever 
been very useful, it seems to have been rather by their eme- 
tic, than by their expectorant powers. 

When the inflammatory affections of the lungs seem to 
be considerable, it is proper, besides blood-letting, to ap- 
ply blisters on some part of the thorax. 

As a cough is often the most troublesome circumstance of 
this disease, so demulcents may be employed to alleviate it. 
See 373. 

But after the inflammatory symptoms have much abated, 
if the cough should still continue, opiates afford the most 
effectual means of relieving it ; and in the circumstances 
just now mentioned, they may be very safely employed. 
'See 375. 

After the inflammatory and febrile states of this disease 
are almost entirely gone, the most effectual means of dis- 
cussing all remains of the catarrhal affection, is by some ex- 
ercise of gestation diligently employed. 



CHAPTER II. 

OF THE DYSENTERY. 

1066.] r T~ v HE dysentery is a disease in which the patient 
JL has frequent stools accompanied with much 
griping, and followed by a tenesmus. The stools, though 
frequent, are generally in small quantity ; and the matter 
voided is chiefly mucus, sometimes mixed with blood. At 
the same time the natural fieces seldom appear, and, when 
they do, it is generally in a compact and hardened form. 

1067.] This disease occurs especially in summer and au- 
tumn, at the same time with autumnal intermittent and re- 
mittent fevers ; and with these it is sometimes combined or 
complicated.* 

* The ammoniac and squills may be joined together in the following form : 

R. Lac ammoniac Siv. 
Syr. scillit. §iii. 
M. 

This mixture must be acknowledged to be somewhat nauseous, but it has considerable em- 
c.icy. The dose of it is two, or, if the stomach can bear it, three table-spoonfuls twice a-day. 

+ It appears more especially in armies encamped in lew swampy grounds, and, without pro- 
per management, is highly (JestructiTe. 



PRACTICE OF PHYSIC. 337 

1068.] The disease comes on sometimes with cold shiver- 
ings, and other symptoms of pyrexia ; but more commonly 
the symptoms of the topical affection appear first. The 
beJJy is costive, with an unusual flatulence in the bowels. 
Sometimes, though more rarely, some degree of diarrhoea 
is the first appearance. In most cases the disease begins 
with griping, and a frequent inclination to goto stool. In 
indulging this, little is voided ; but some tenesmus attends 
it. By degrees, the stools become more frequent, the grip- 
ing more severe, and the tenesmus more considerable. 
Along with these symptoms there is a loss of appetite ; and 
frequently sickness, nausea, and vomiting, also affecting the 
patient. At the same time there is always more or less of 
pyrexia present, which is sometimes of the remittent kind, 
and observes a tertian period. Sometimes the fever is ma- 
nifestly inflammatory, and very often of a putrid kind. 
These febrile states continue to accompany the disease dur- 
ing its whole course, especially when it terminates soon in a 
fatal manner. In other cases, the febrile state almost en- 
tirely disappears, while the proper dysenteric symptoms re- 
main for a long time after. 

1069.] In the course of the disease, whether of a shorter 
or longer duration, the matter voided by stool is very va- 
rious. Sometimes it is merely a mucous matter, without 
any blood, exhibiting that disease which Dr. Roderer has 
named the morbus ynucosus, and others the dysmteria alba. 
For the most part, however, the mucus dicharged is more 
or less mixed with blood. This sometimes appears only in 
streaks amongst the mucus ; but at other times is more co- 
pious, tinging the whole of the matter discharged ; and up- 
on some occasions a pure and unmixed blood is voided iri 
considerable quantity. In other respects, the matter voided 
is variously changed in color and consistence, and is com- 
monly of a strong and unusually fetid odor. It is probable, 
that sometimes a genuine pus is voided ; and frequently a 
putrid sanies, proceeding from gangrenous parts. There 
are very often mixed with the liquid matter some films of a 
membranous appearance, and frequently some small masses 
of a seemingly sebacious matter. 

1070.] While the stools consisting of these various mat- 
ters are in many instances, exceedingly frequent, it is sel- 
dom that natural feces appear in them ; and when they do 
appear, it is, as I have mentioned, in the form of scybala, 
that is, in somewhat hardened, separate balls. When these 

21 x 



338 PRACTICE OF PHYSIC. 

are voided, whether by the efforts of nature, or as soli- 
cited by art, they procure a remission of all the symptoms, 
and more especially of the frequent stools, griping, and 
tenesmus. 

1071.] Accompanied with these circumstances, the dis- 
ease proceeds for a longer or a shorter time. YY'hen the py- 
rexia attending it is of a violent inflammatory kind, and 
more especially when it is of a very putrid nature, the dis- 
ease often terminates fatally in a very few days, with all 
the marks of a supervening gangrene. When the febrile 
state is more moderate, or disappears altogether, the dis- 
ease is often protracted for weeks, and even for months ; 
but even then, after a various duration, it often teminates 
fatally, and generally in consequence of a return and con- 
siderable aggravation of the inflammatory and putrid states. 
In some cases the disease ceases spontaneously ; the frequen- 
cy of stools, the griping, and tenesmus, gradually diminish- 
ing, while natural stools return. In other cases, the disease 
with moderate symptoms, continues long, and ends in a di- 
arrhoea, sometimes accompanied with lienteric symptoms. 

1072.] The remote causes of this disease have been va- 
riously judged of. It generally arises in summer or autumn 
after considerable heats have prevailed for some time, and 
especially after very warm, and at the same time very dry 
states of the weather ; and the disease is more frequent in 
warm, than in cooler climates. — It happens, therefore, in 
the same circumstan :es and seasons which considerably af- 
fect the state of the bile in the human body ; but as the 
cholera is often without any dysenteric symptoms, and co- 
pious discharges of bile have been found to relieve the symp- 
toms of dysentery, it is difficult to determine what connec- 
tion this disease has with the state of the bile. 

1073.] It has been observed, that the effluvia from very 
putrid animal substances, readily affect the alimentary ca- 
nal ; and upon some occasions they certainly produce a di- 
arrhiea ; but, whether they ever produce a genuine djsen- 
tery, I have not been able to learn with certainty. 

1074.] The dysentery docs often manifestly arise from 
the application of cold, but the disease is always contagious : 
and, by the propagation of such contagion, independent 
of cold, or other exciting causes, it becomes epidemic in 
camps and other places. It is, therefore, to be doubted, if 
the application of cold does overproduce the disease, unless 
where the specific contagion has been previously received 



PRACTICE OF PHYSIC. 339 

into the body : And, upon the whole, it is probable, that 
a specific contagion is to be considered us always the remote 
cause of this disease. 

1075.] Whether this contagion, like many others, be of 
a permanent nature, and only shows its effects in certain 
circumstances which render it active, or if it be occasionally 
produced, I cannot determine. Neither, if the latter sup- 
position be received, can I say by what means it may be ge- 
nerated. As Jittle do we know any thing of its nature con- 
sidered in itself; or at most this onlv, that, in common 
with many other contagions, it appears to be commonly of 
a putrid nature, and capable of inducing a putrescent ten- 
dency in the human body. This, however, does not at 
all explain its peculiar power in inducing those symptoms 
which properly and essentially constitute the disease of 
dysentery. (1066.) 

1076.] Of these symptoms the proximate cause is still 
obscure. The common opinion has been, that the disease 
depends upon an acrid matter received into, or generated 
in the intestines themselves, exciting their peristaltic mo- 
tion, and thereby producing the frequent stools which occur 
in this disease. Put this supposition cannot be admitted ; 
for in all the instances known of acrid substances applied to 
the intestines and producing frequent stools, they at the 
same time produce copious stools, as might be expected 
from acrid substances applied to any length of the intestines. 
This, however, is not the case in dysentery ; in which the 
stools, however frequent, are generally in very small quan- 
tity, and such as may be supposed to proceed from the lower 
parts of the rectum only. With respect to the superior 
portions of the intestines, and particularly those of the colon, 
it is probable they are under a preternatural and considera- 
ble degree of constriction : For, as I have observed above, 
the natural faeces are seldom voided ; and when they arc, it 
is in a form which gives reason to suppose, they have been 
Jong retained in the cells of the colon, and consequently 
that the colon had been affected with a preternatural eon 
striction. This is confirmed by almost all the, dissections 
which have been made of the bodies of dysenteric patients. 
in which, when gangrene had not entirely destroyed th<^ 
texture and form of the parts, considerable portions of the 
great guts have been found affected with a very considera- 
ble constriction. 

1077.] I apprehend, therefore, that the proximate cause 



340 PRACTICE OF PHYSIC. 

of dysentery, or at least the chief part of the proximate 
cause, consists in a preternatural constriction of the colon, 
occasioning at the same time those spasmodic efforts which 
are felt in severe gripings, and which efforts, propagated 
downwards to the rectum, occasion there the frequent mu- 
cous stools and tenesmus. But, whether this explanation 
shall be admitted or not, it will still remain certain, that 
hardened faeces retained in the colon are the cause of the 
griping, frequent stools, and tenesmus ; for the evacuation 
of these faeces, whether by nature or by art, gives relief 
from the symptoms mentioned ; and it will be more fully 
and usefully confirmed by this, that the most immediate 
and successful cure of dysentery is obtained by an early and 
constant attention to the preventing the constriction, and 
the frequent stagnation of faeces in the colon. 

1078.] In this manner I have endeavored to ascertain the 
proximate cause of dysentery, and therefore to point out 
also the principal part of the cure, which, from want of the 
proper view of the nature of the disease, seems to have been 
in several respects fluctuating and undetermined among 
practitioners. 

1079.] The most eminent of our late practitioners, and 
of the greatest experience in this disease, seem to be of 
opinion, that the disease is to be cured most effectually by 
purging assiduously employed. The means may be vari- 
ous ; but the most gentle laxatives are usually sufficient ; 
and as they must be frequently repeated, the most gentle 
are the most safe ; the more especially as an inflammatory 
state so frequently accompanies the disease. Whatever 
laxatives produce an evacuation of natural faeces, and a 
consequent remission of the symptoms, will be sufficient 
to effectuate the cure. But if gentle laxatives shall not 
produce the evacuation now mentioned, some more pow- 
erful medicines must be employed ;* and 1 have found no- 

• I shall subjoin some formulas suitable for procuring a passage in the dysentery. 

R. Infus. senn. §ii. 
Mannse opt. §i, 
M. f. haust. 

R. Mannae Si- 
Sal, glauber. Bss. 

Solve in aq. bullient. Siii. ; et adde 
Tinct. Cardamomi 3i. 

Where slronsjer purgatives are requisite, 

R. Resin. Jalap, gr. x. vel xv. 

Tere in mortario marmoreo, cum 



PRACTICE OF PHYSIC. 341 

thing more proper or convenient than tartar emetic, given 
in small doses, and at such intervals as may determine their 
operation to be chiefly by stool. Rhubard, so frequently 
employed, is in several respects amongst the most impro- 
per purgatives. 

1080.] Vomiting has been held a principal remedy in 
this disease; and may be usefully employed in the begin- 
ning of it, with a view to both the state of the stomach and 
of the fever ; but it is not necessary to repeat it often ; and 
unless the emetics employed operate also by stool, they 
are of little service. Ipecacuanha seems to possess no 
specific power ; and it proves only useful when so ma- 
naged as to operate chiefly by stool. 

1081.] For relieving the constriction of the colon, and 
evacuating the retained faeces,* glysters may sometimes be 
useful , but they are seldom so effectual as laxatives given 
by the mouth ; and acrid glysters, if they be not effectual 
in evacuating the colon, may prove hurtful by stimulating 
the rectum too much. 

1082.] The frequent and severe griping attending this 
disease, leads almost necessarily to the use of opiates, and 
they are very effectual for the purpose of relieving from 
the gripes ; but by occasioning an interruption of the action 
of the small guts, they favor the constriction of the co- 
Ion, and thereby sometimes aggravate the disease ; and if 
at the same time the use of them supersede in any measure 
the employing of purgatives, it commonly does much 
mischief; 1 believe it indeed to be only the neglect of purg- 
ing that renders the use of opiates very necessary, f 

1083.] When the gripes are both frequent and severe, 
they may sometimes be relieved by the employment of a 
semicupium, or by a fomentation of the abdomen, conti- 
nued for some time. In the same case, the pains may be 
relieved, and, as I think, the constriction of the colon may 
be taken off, by blisters applied to the lower belly. J 

Amygdal. dulc. decort. No. iii. 

Sacch. alb. 3i« > 

Dein addc 

Aq. cinnamom. simpl. Biss. 

M. 

• Gljrsters in these cases ought to be made very large, and they ought also to be very mild ; 
as a pint and a half, or even two pints, of thin lintsced tea, or decoction of marsh mallows, 
without any other addition. 

+ The griping is much relieved, and sometimes prevented, by drinking plentifully of any 
mucilaginous warm liquors during the operation of the purges; as barley water, with bruised 
prunes boiled in it. 

% Blisters applied to the abdomen, besides being excessively troablesome, must necessarily be 
extremely painful. 



342 PRACTICE OF PHYSIC. 

1034.] At the beginning of this disease, when the fever 
is any way considerable, blood-letting, in patients of to- 
lerable vigor, may be proper and necessary; and, when 
the pulse is full and hard, with other symptoms of an in- 
flammatory disposition, blood-letting ought to be repeated. 
But, as the fever attending dysentery is often of a putrid 
kind, or does, in the course of the disease, become soon 
of that nature, blood-letting must be employed with great 
caution. 

1085.} From the account now given of the nature of this 
disease, it will be sufficiently obvious, that the use of astrin- 
gents in the beginning of it must be absolutely pernicious. 

1086.] Whether an acrid matter be the original cause of 
this disease may be uncertain; but from the indigestion 
and the stagnation of fluids in the stomach which attend the 
disease, it may be presumed, that some acrid matters are 
constantly present in the stomach and intestines, and there- 
fore that demulcents may be always usefully employed. 
At the same time, from this consideration that mild oily 
matters thrown into the intestines in considerable quantity 
always prove laxative, I am of opinion that the oleaginous 
demulcents are the most useful.* 

1087.] As this disease is so often of an inflammatory or 
of a putrid nature, it is evident that the diet employed in it 
should be vegetable and acescent. Milk in its entire state 

Practitioners have probably been deceived in thinking that blisters have relieved gripings in 
the dysentery, for they are seldom employed alone ; and the effects of purser and diluents have 
perhaps been mistaken for the effects of a blister that might have happened to have been ap- 
plied at the time when these other remedies were used. Too strict an attention to the false 
axiom, post hoc ergo propter hoc, has been the source of numerous errors in the practice of phy- 
sic, and has raised the reputation of the physician and his remedies, when the merit was only 
due to nature. 

* Some forms of these demulcents are given in the Pharmacopoeias. The following mav be 
added, for the sake of variety, as the patient frequently loatiis Linctuses. 

R. Mann, opt, 

Ol. amygdal. recent, aa. *i. 

Syr. e Cort. aurant. §ss. 

M. 
R. Syr. althasse. 

01. amygdal. 

Elect, lenitiv. aa. §i. 

M. 
R. Conserv. cynosbat. 31. 

Syr. rosar. 

01. amygdal. aa. Sii. 

M. 

Two te3 -spoonfuls of any of the above tinctures may be given every hoar, or every other 
hour, drinking, at the same lime, barley-water wiih bruised prunes bo'ileo in it. The cure ot 
the dysentery is briefly comprehended in' keeping the btliy open, and usin , dilu- 

ents and lubricants. 



PRACTICE OF PHYSIC. 343 

is of doubtful quality in many crises; but some portion of 
the cream is often allowable, and whey is always proper. 

In the first stages of the disease, the sweet and subacid 
fruits are allowable, ', nd evem proper. It is in the more 
advanced stages only tbat any morbid acidity seems to pre- 
vail in tbe stomach, and to require seme reserve in the use 
of acesccnts. At the beginning of the disease, absorbents 
seem to be superfluous; and by their astringent and septic 
powers they may be hurtful. 

10«8.] When this disease is complicated with an inter- 
mittent fever, and is protracted from that circumstance 
chiefly, it is to be treated as an intermittent, by adminis- 
tering the Peruvian bark, which however, in the earlier 
periods of the disease, is hardly to be admitted. 



PART II. 

OF NEUROSES, OR NERVOUS DISEASES. 

1089.] TN a certain view, almost the whole of the dis- 
X eases of the human body might be called ner- 
vous: but there would be no use for such a general appel- 
lation ; and on the other hand, it seems improper to limit the 
term, in the loose inaccurate manner in which it has been 
hitherto applied, to hysteric or hypochondriacal disorders, 
which are themselves hardly to be defined with sufficient 
precision. 

1090.] In this place I propose to comprehend, under the 
title of neuroses, all those preternatural affections of sense 
or motion Which are without pyrexia, as a part of the pri- 
mary disease ; and all those which do not depend upon a to- 
pical affection of the organs, but upon a more general af- 
fection of the nervous system, and of those powers of the 
system upon which sense^ and motion more especially depend. 

1091.] Of such diseases I have established a class, under 
the title of neuroses or nervous diseases. These I again 
distinguish, as they consist, either in the interruption and 
debility of the powers of sense and motion, or in the irre- 
gularity with which these powers are exercised ; and have 
accordingly arranged them under the four orders of Comala y 
Adynamia', Spasmi, and Vesanitc, to be defined as w« pro- 
ceed to treat of them more particularly. 



344 PRACTICE OF PHYSIC. 



BO OKI. 

OF COMATA, OR THE LOSS OF VOLUN- 
TARY MOTION. 

1092.]* T TNDER this title are comprehended those af~ 
V_-/ fections which have been commonly called 
the Soporose diseases ; but they are most properly distin- 
guished by their consisting in some interruption or suppres- 
sion of the powers of sense and voluntary motion, or of 
what are called the animal functions. These are indeed usu- 
ally suspended in the time of natural sleep : But of all the 
diseases to be comprehended under our title, sleep, or even 
the appearance of it, is not constantly a symptom. Of 
such diseases I can mark and properly explain two genera 
only, which come under the title of Apoplexy and Palsy. 



CHAPTER I. 

OF APOPLEXY. 

1093.] A POPLEXY is that disease in which the whole 
-ZjL of the external and internal senses, and the 
whole of the voluntary motions, are in some degree abolish- 
ed ; while respiration and the action of the heart continue 
to be performed.* By its being an affection of the whole of 
the powers of sense and of voluntary motion, we distinguish 
it from Palsy; and by its being with the continuance of res- 
piration and the action of the heart, it is distinguished from 
Syncope. I have further added to the ordinary definition of 
Apoplexy, that the abolition of the powers of sense and mo - 
tion is in some degree only ; meaning by this to imply, that 
under the title of Apoplexy, are here comprehended those 
diseases which, as differing from it in degree only, cannot 

» " The appearance of a profound and continual sleep," is by Boerhaave judiciously added 
to the definition of Apoplexy. To distinguish between a profound sleep and apoplexy which 
Tery much resemble each other, is, however, extremely easy. A man in a profound sleeD 
may in general be roused by the application of strong stimulants to the organs of seme which 
produce no effect on an apoplectic patient. To distinguish between apoplexy and 'a fit of 
drunkenness, is not so easy ; for drunken people are sometimes incapable of being roused bv 
any stimulants, remaining totally insensible and motionless. The fumes of the liouor with 
which they have been intoxicated may sometimes be discovered by smelling • A drunken 6t 
■"y also be known by the paleness of the drunken man's face, and by his manner of living 



PRACTICE OF PHYSIC. 345 

with a view either to pathology or practice, be properly 
distinguished from it : Such are the diseases sometimes 
treated of under the names of Cams, Cataphora, Coma, 
and Lethargus. 

1094.] Apoplexy, in all its different degrees, most com- 
monly affects persons advanced in life, and especially those 
above sixty years of age. It most usually affects persons 
of large heads and short necks,* persons of a corpulent 
habit, persons who have passed an indolent life and used a 
full diet, and especially those who have indulged in frequent 
intoxication. Men who have long labored under a frequent 
and copious discharge of blood from the hemorrhoidal ves- 
sels, upon either the suppression or spontaneous ceasing of 
that discharge, are particularly liable to be affected with 
apoplexy. 

1095.] This disease frequently comes on very suddenly: 
But in many cases it is preceded by various symptoms, such 
as frequent fits of giddiness, frequent headachs, a hemor- 
rhagy from the nose, some transitory interruption of seeino- 
and hearing, some false vision and hearing, some transitory 
degree of numbness or loss of motion in the. extremities, 
some faultering of the tongue in speaking, a loss of memo- 
ry, a frequent drowsiness, and frequent fits of incubus. 

1096.] An attention to these symptoms, and to the pre- 
disponent circumstances (1094.) will often enable us to 
foresee the more violent attacks of this disease. 

1097.] When the disease comes on suddenly to a consi- 
derable degree, it has been frequently observed to have been 
immediately induced by violent exercise, by a full and long 
continued inspiration ; by a fit of anger ; by much exter- 
nal heat, especially that arising from a crowded assembly of 
people ; by warm bathing ; by intoxication ; by long stoop- 
ing with the head down ; and by a tight ligature about the 
neck. The disease has been remarked to make its attacks 
most frequently in the spring season, and especially when 
the vernal heat suddenly succeeds to the winter cold. 

1098.] The symptoms denoting the presence of this dis- 
ease will be sufficiently known from the definition given 
1093. Although the whole of the body is affected with 
the loss of sense and motion, it sometimes takes place more 
upon one side of the body than the other ; and in that case 
the side least affected with palsy is sometimes affected with 

• Different authors, one of wheen is Boerhaave, have supposed that a rcrtcbra is sometimes 
wanting, the neck consisting only of six instead of seven Tcrtebrae. 

2 Y 



346 PRACTICE OF PHYSIC. 

convulsions. In this disease there is often a stertorous 
breathing : and this has been said to be a mark of the most 
violent state of the disease : but it is not always present 
even in the most complete form or most violent degree of 
the disease. 

1099.] The proximate cause of this disease may be, in 
general, whatever interrupts the motion of the nervous pow- 
er from the brain to the muscles, from voluntary motion ; 
or, in so far as sense is affected, whatever interrupts the 
motion of the nervous power from the sentient extremities 
of the nerves to the brain. 

1 100.] Such an interruption of the motions of the ner- 
vous power may be occasioned, either by some compression 
of the origin of the nerves, or by something destroying the 
mobility of the nervous power. Both these causes we must 
treat of more particularly ; and, first, of that of compres- 
sion, seemingly the most frequent occasion of apoplexy, 
and perhaps the occasion of all those apoplexies arising from 
internal causes. 

1101.] The loss of sense and motion in particular parts 
of the body, may be occasioned by a compression, either 
of the origin of certain nerves only, or of the same nerves 
in some part of their course from the brain to the organs of 
sense and motion. Such cases of partial compression will 
be more properly considered hereafter ; and the affection I 
am now to treat of being general, it must depend upon a 
very general compression of the origin of the nerves, or 
medullary portion of the brain ; and therefore, this more 
general compression only is to be considered here. 

1102.] This compression of the origin of the nerves, or 
medullary portion of the brain, may be produced in differ- 
ent ways ; as, 

1. By External violence fracturing and pressing in a part 
of the cranium. 

2. By tumors, sometimes soft, sometimes bony, formed 
in different parts of the brain, or in its membranes, and 
becoming of such a bulk as to compress the medullary 
substance of the brain. 

3.. By the blood being accumulated in the blood-vessels 
of the brain, and distending them to such a degree as to 
compress the medullary portion of the same. 

4. By fluids effused in different parts of the brain, or in- 
to the cavity of the cranium, and accumulated in such 
quantity as to occasion the compression we treat of. 



PRACTICE OF PHYSIC. 347 

And, as to this last, it is to be remarked here, that the 
fluids effused may be of two kinds; that is, they may be 
either a portion of the common mass of blood, poured out 
from red vessels ,- or a portion of serum or colorless fluid, 
poured out chiefly by exhalauts. 

1103.] Of these several causes of compression, the first 
is not to be considered here, because the removing it does 
not belong to our province; and the consideration of the 
second may be omitted, as in most instances it is neither to 
be discerned nor cured by any means yet known. The 
third and fourth causes of compression, as- they are the 
most frequent, and are also most properly the subjects of 
our art, so they are those which deserve our particular at- 
tention : and we shall therefore endeavor to trace them 
further back in theseries of causes which may produce them. 

1 104.] Both the states of over distention and of effusion 
may be produced by whatever increases the afflux and im- 
petus of the blood in the arteries of the head ; such as vio- 
lent exercise, a violent fit of anger, external heat appli- 
ed, or any strong pressure upon the descending aorta. 

1105.] But both these states of over distention and of 
effusion, may also and seem to be more frequently produ- 
ced by causes that operate by preventing the free return 
of the venous blood from the vessels of the head to the 
right ventricle of the heart. 

1106.] The venous vessels of the brain are of a confor- 
mation and distribution so peculiar, as to lead us to believe, 
that Nature intended to retard the motion of the blood, 
and accumulate it in these vessels; and therefore, even ve- 
ry small additional resistances to the motion of the blood 
frorn these towards the right ventricle of the heart, may 
still more readily accumulate the blood in them. Such ac- 
cumulation will most readily happen in advanced life, when 
the venous s}'stem in general is in a plethoric state, and 
when this plethora takes place especially* in the venous ves- 
sels of the brain. It will, in like manner, be most apt to 
occur in persons whose heads are large with respect to the 
rest of the body; and in persons of a short neck, which is 
unfavorable to the return of the venous blood from the 
head. The accumulation of blood in the venous vessels of 
the brain, will also be most likely to occur in persons of a 
corpulent habit, either because these may be considered 
to be in a plethoric state, or because obesity, by occasion- 
ing a compression of the blood-vessels in other parts of 



348 PRACTICE OF PHYSIC. 

the body, more readily fills those of the brain, which are 
entirely free from any such compression. 

1107.] These are the circumstances in the constitution 
of the body, which, producing a slower motion and return 
of the venous blood from the vessels of the head, favor an 
accumulation and distention in them ; and we now proceed 
to mention the several occasional causes, which, in every 
person, may directly prevent the free return of the blood 
from the vessels of the head towards the heart. Such are, 

1. Stooping down with the head, or other situations of 
the body in which the head is long kept in a depending 
state, and in which the gravity of the blood increases the 
afflux of it by the arteries, and opposes the return of it by 
the veins. 

2. A tight ligature about the neck, which compresses the 
veins more strongly than the arteries, 

3. Any obstruction of a considerable number of the veins 
carrying the blood from the head, and more especially any 
considerable obstruction of the ascending vena cava. 

4. Any considerable impediment of the free passage of 
the blood from the veins into the right ventriele of the heart ; 
and it is commonly by this, and the immediately preceding 
circumstances, that polypous concretions in the cava, or 
right ventricle, are found to occasion apoplexy. 

5. The return of blood from the veins of the head to- 
wards the heart, is especially interrupted by every circum- 
stance that produces a more difficult transmission of the 
blood through the vessels of the lungs. It is well known, 
that, at the end of every expiration, some interruption is 
given to the free transmission of the blood through the 
lungs ; and that this at the same time gives an interruption 
to the motion of the blood from the veins into the right 
ventricle of the heart. This clearly appears from that re- 
gurgitation of the blood in the veins, which occasions the 
alternate heaving and subsiding that is perceived in the 
brain of living animals when the cranium is removed, and 
which is observed to be synchronous with the alternate mo- 
tions of respiration. From this we readilv perceive, that 
Avhafever occasions a difficulty in the transmission of the 
blood through the limps, must also interrupt the free return 
of the venous blood from the vessels or the head ; and 
must therefore favor, and perhaps produce, an accumu- 
lation or blood, and an over-distention in these vessels. 

It js further to be observed, that as a very fullinspira- 



PRACTICE OF PHYSIC. 349 

tion, continued for any length of time, occasions such an 
interruption of the free transmission of the blood through 
the lungs, as produces a suffusion of face, and a manifest 
turgescence of the blood-vessels of the head and neck ; so 
every full and long continued inspiration may occasion an 
accumulation of blood in the vessels of the head, to a very 
considerable degree. Thus, as every strong exertion of 
the muscular force of the body requires, and is attended 
with, a very full and long continued inspiration, we thence 
learn why the violent exertions of muscular force have been 
so often the immediate or exciting causes of apoplexy. 

It may also be remarked, that corpulency and obesity 
seem to operate very much, by occasioning a more diffi- 
cult transmission of the blood through the vessels of the 
lungs. It appears, that in fat persons, from the compres- 
sion of the blood vessels in many parts of the body, the 
vessels of the lungs are thereby kept very full ; so that up- 
on the least increase of bodily motion, which sends the 
blood faster into the lungs, a more frequent and laborious 
respiration becomes in such persons immediately necessary. 
This shows, that, in such persons, the blood is not freely 
transmitted through the lungs ; a circumstance which, as 
in other instances, must give a constant resistance to the 
return of blood from the vessels of the head, and therefore 
favor or occasion an accumulation of blood in them. 

Is the motion of the blood in the vessels of the head ren- 
dered slower by study, care, and anxiety ? 

1108.] It is to be observed further, that these several 
causes (1104. — 1107.) of a preternatural fulness in the* 
blood-vessels of the brain, ma3* produce apoplexy in dif- 
ferent ways, according as the fulness takes place in the ar- 
teries or in the veins. 

1109.] Accordingly,^'^, the increased afflux of blood 
into the arteries of the brain, and an increased action in 
these, may either occasion a rupture of their extremities, 
and thereby an effusion of red blood producing compres- 
sion ; or the same afflux and increased action may occa- 
sion an increased exhalation from their extremities, of a 
serous fluid, which, if not as quickly re-absorbed, may soon 
accumulate in such quantity as to produce compression. 

1110.] Secondly, The plethoric state of the venous ves- 
sels of the brain, may operate in three different* ways, 

1. The fulness of the veins may give such resistance to 
the blood flowing into them from the arteries, as to deter- 



350 PRACTICE OF PHYSIC. 

mine the impetus of the blood to be so much greater upon 
the extremities of the arteries as to occasion a rupture of 
these, and consequently an effusion of red blood, or the 
H<emorrhagia cerebri, which Hoffman considers as a 
frequent cause of apoplexy, and which we have before ex- 
plained in 771. 

2. Whilst the same resistance to the blood flowing from 
the arteries into the veins, increases the impetus of the 
blood to the former, this may, without occasioning rup- 
ture, increase the exhalation from their exhalant extremi- 
ties, and produce an effusion of a serous fluid ; in the same 
manner as such resistance in the veins produces hydropic 
effusions in other parts of the body. 

3. If we may suppose, as no lymphatics have been yet 
discovered in the brain, that the ordinary absorbents are 
not present there, and that the exhaled fluids are absorbed 
or taken up by the extremities of the veins ; this will show 
still more clearly that a resistance to the motion of the blood 
in the veins of the brain, may readily produce an accumu- 
lation of serous fluid in its cavities, and consequentlv a 
compression producing apoplexy. 

1111.] Besides these causes of apoplexy from afflux in 
the arteries, or resistance in the veins, an effusion of serum 
may happen from two other causes. The one is a relaxa- 
tion of the exhalants, as in other cases of hydropic dia- 
thesis prevailing in the body ; and it is not unusual for a 
general dropsy to end in apoplexy. The second is an over 
proportion of watery parts in the mass of blood, which is 
therefore ready to run off by the exhalants, as in the case 
of an ischuria renalis ; which, when it proves incurable, 
very commonly terminates in apoplexy. 

1112.] We have now mentioned the several causes of 
apoplexy depending upon compression ; and from the whole 
it will appear, that the most frequent of all these causes is a 
plethoric state, or an accumulation and congestion of blood 
in the venous vessels of the head, operating, according to 
its degree, in producing over-distention or effusion. The 
frequent operation of such a cause will especially appear 
from a consideration of the predisponent circumstances 
(1094.) and from the antecedent symptoms. (1095.) 

1 1 1 3.] From the view I have now given of the causes of 
apoplexy arising from compression, it will readily appear 
that there is a foundation for the common distinction of 
this disease into the two kinds of Sanguine and Serous. 



PRACTICE OF PHYSIC. 351 

But this distinction cannot be very usefully applied in prac- 
tice, as both kinds may often depend on the same cause, 
that is, a venous plethora, and therefore requiring very 
nearJy the same method of cure. The only distinction 
that can be properly made of apoplexies from compres- 
sion, is perhaps the distinction of serous apoplexy, into 
that depending on the plethora mentioned (1112.) and that 
depending on hydropic diathesis or an over proportion of 
water in the blood ; (1111.) the former causes giving a pro- 
per idiopathic, the latter only a symptomatic disease. 

1114.] Beside the causes now mentioned, occasioning 
apoplexy by compression, I alledge there are other causes 
producing the same disease, by directly destroying the mo- 
bility of the nervous power. Such causes seem to be the 
mephitic, arising from fermenting liquors, and from many 
other sources ; the fumes arising from burning charcoal ; 
the fumes of mercury, of lead, and of some other metal- 
lic substances ; opium, alcohol, and many other narcotic 
poisons : to all which I would add the power of cold, of 
concussion, of electricity, and of certain passions of the 
mind. 

1115.] None of these poisons or noxious powers seem 
to kill by acting first upon the organs of respiration, or up- 
on the sanguiferous system ; and I believe their immediate 
and direct action to be upon the nervous power, destroying 
its mobility, because the same poisons show their power in 
destroying the irritability of muscles and of the nerves 
connected with them, when both these are entirely sepa- 
rated from the rest of the body. 

1116.] It appears to me probable, that the apoplectic 
state in some degree accompanying, and almost always 
succeeding, an epileptic paroxysm, does not depend upon 
compression, but upon a certain state of immobility of 
the nervous power, produced by certain circumstances in 
the nervous system itself, which sometimes seem to be 
communicated from one part of the body to another, and 
at length to the brain. 

1 1 17.] The same observation may be made with respect 
to many instances of hysteric paroxysm ; and the circum- 
stances, both of epileptic and hysteric paroxysms, ending 
in coma, or a degree of apoplexy, lead me to think, that 
also the apoplexy proceeding from retrocedent or atonic 
gout is of the same kind, or that it depends upon an immo- 
bility of the nervous power, rather than upon compression. 



252 PRACTICE OF PHYSIC. 

1118.] It may indeed happen, that as the apoplectic and 
gouty predispositions do often concur in the same person ; 
so it may consequently happen, that the apoplexy coming 
upon gouty persons, may sometimes depend upon com- 
pression ; and dissections may, accordingly, discover that 
the circumstances of such a cause had preceded. But, in 
many cases of the apoplexy following a retrocedent or 
atonic gout, no such antecedent or concomitant circum- 
stances, as commonly occur in cases of compression, do 
distinctly or clearly appear ; while others present them- 
selves, which point out an affection of the nervous power 
alone. 

1119.] With respect, however, to the circumstances 
which may appear upon the dissection of persons dead of 
apoplexy, there may be some fallacy in judging, from 
those circumstances, of the cause of the disease. What- 
ever takes off or diminishes the mobility of the nervous 
power, may very much retard the motion of the blood in 
the vessels of the brain ; and that perhaps to the degree of 
increasing exhalation, or even of occasioning rupture and 
effusion : so that, in such cases, the marks of compression 
may appear, upon dissection, though the disease had truly 
depended on causes destroying the mobility of the nervous 
power. This seems to be illustrated and confirmed from 
what occurs in many cases of epilepsy. In some of these, 
after a repetition of fits, recovered from in the usual man- 
ner, a fatuity is induced, which commonly depends upon 
a watery inundation of the brain : and in other cases of 
epilepsy, when fits have been often repeated without any 
permanent consequence, there happens at length a fatal 
paroxysm ; and upon dissection it appears, that an effusion 
of blood had happened. This, I think, is to be consider- 
ed as a cause of death, not as a cause of the disease : for 
in such cases, I suppose that the disease had diminished 
the action of the vessels of the brain, and thereby given 
occasion to a stagnation, which produced the appearances 
mentioned. And I apprehend the same reasoning will ap- 
ply to the cases of retrocedent gout, which, by destroy- 
ing the energy of the brain, may occasion such a stagnation 
as will produce rupture, effusion, and death ; and in such a 
case, the appearances upon dissection might lead us to think 
that the apoplexy had depended entirely upon compression. 

1 120.] The several causes mentioned in 1114, are often 
of such power as to occasion immediate death ; and there- 



PRACTICE OF PHYSIC. 353 

fore have not commonly been taken notice of as affording 
instances of apoplexy ; but, as the operation of the whole 
of these causes is similar and analogous, and as in most in- 
stances of the operation of these causes an apoplectic state 
is manifestly produced, there can be little doubt in consi- 
dering most of the instances of their effects as cases of apo- 
plexy, and therefore such as fall properly under our consi- 
deration here. 

1121.] This disease of apoplexy is sometimes entirely 
recovered from ; but more frequently it ends in death, or 
in a hemiplegia. Even when an attack of the disease is re- 
covered from, we generally find it disposed to return ; and 
the repeated attacks of it almost always, sooner or later, 
bring on the events we have mentioned. 

1122.] The several events of this disease, in health, 
death, or another disease, may be expected and foreseen 
from a consideration of the predisponent circumstances 
(1094.) of the antecedent symptoms (1095.) of the exciting 
causes (1097.) of the violence and degree of the symptoms 
when the disease has come on (1093.) of the duration of 
the disease ; and the effects of the remedies employed. 

1123.] From the great danger attending this disease 
when it has come on (1121.) it will readily appear, that 
our care should be chiefly directed to the prevention of it. 
This, I think, may be often done by avoiding the remote 
and exciting causes ; and how this may be accomplished, 
will be obvious from the enumeration of those causes given 
above (1097.) But it will also appear from what is said 
above, that the prevention of this disease will especially 
depend upon obviating the predisponent cause ; which, in 
most cases, seems to be a plethoric state of the blood-ves- 
sels of the brain. This, 1 think, may be obviated by dif- 
ferent means ; and, in the first place, by a proper manage- 
ment of exercise and diet. 

1124.] The exercise ought to be such as may support 
the perspiration, without heating the body or hurrying 
respiration; and, therefore, commonly by some mode of 
gestation. In persons not liable to frequent fits of giddi- 
ness, and who are accustomed to riding on horseback, this 
exercise is, of all others the best. Walking, and some 
other modes of bodily exercise, may be employed with the 
restrictions just now mentioned ; but in old men, and in 
men of corpulent habits, bodily exercise ought always tube 
very moderate. 

Sz 



354 PRACTICE OF PHYSIC. 

1 125.] In persons who pretty earlv in life show the pre- 
disposition to apoplexy, it is probable that a low diet, with 
a good deal of exercise ; might entirely prevent the disease ; 
but, in persons who are advanced in lire before they think 
of taking precautions, and are at the same time of a cor- 
pulent habit, which generally supposes their having been 
accustomed to full living, it might not be safe to put them 
upon a low diet; and it may be enough that their diet be 
rendered more moderate than usual, especially with res- 
pect to animal food; and that, at supper, such food should 
be abstained from altogether. 

In drinking, all heating liquors, are to be abstained from, 
2s much as former habits will allow and the smallest ap- 
proach to intoxication is to be carefully shunned. For or- 
dinary draught, small beer is to be preferred to plain wa- 
ter, as the latter is more ready to occasion costiveness, which 
in apoplectic habits is to be carefully avoided. The large 
use of tobacco in any shape may be hurtful; and except 
in cases where it has been accustomed to, occasion a copi- 
ous excretion from the head, the interruption of which 
might not be safe, the use of tobacco should be avoided ; 
and even in the circumstance mentioned, where it may be 
in some measure necessary, the use of it should at least 
be rendered as moderate as possible. 

1126] Evacuations by stool may certainly contribute 
to relieve the plethoric state of the vessels of the head ; 
and, upon an appearance of any unusual turgescence in 
these, purging will be very properly employed: but, when 
no such turgescence appears, the frequent repetition of 
large purging might weaken the body too much ; and, 
for preventing apoplexy, it may for the most part be 
enough to keep the belly regular, and rather open, by 
gentle laxatives.* In the summer season, it may be useful 
to drink, every morning, of a gentle laxative mineral wai- 
ter, but never in' large quantity. 

1 127.] In the case of a plethoric state of the system, it 
might be supposed that blood-letting would be the most 
effectual means of diminishing the plethora, and of pre- 
venting its consequences; and, when an attack of apo- 

* Gentle laxatives have been often enumerated in the preceding notes. In these cases how- 
ever, there is no danger to be apprehended from the use of the resinous drastics, provided that 
they are not given in sucb dmcs as may weaken lie patient too much. They ought not lo be 
used for the purpose of purging, bm only for keeping ihe body moderately open : and this effect 
may he safely produced by rive or eight grains of Rufutlpjlls t.iken occasionally at bed time or 
by a tea-spoonful or two of the Tmct. jalap, or a tab e-spoonful of the elixir senna; in the mor»- 
tng. The same end may, in many cases, be answeiedby a due attention to diet 



PRACTICE OF PHYSIC. 355 

plexy is immediately threatened, blood-letting is certainly 
the remedy to be depended upon : and blood should be 
taken largely, if it can be done, from the jugular vein, or 
temporal artery. But when no threatening turgescence 
appears, the obviating plethora is not judiciously attempt- 
ed by blood-letting, as we have endeavored to demon- 
strate above, (786.) In doubtful circumstances, leeches 
applied to the temples, or scarifications of the hind-head, 
may be more safe than general bleedings. 

1128.] When there are manifest symptoms of a pletho- 
ric state in the vessels of the head, a seton, or pea-issue, 
near the head, may be very useful in obviating any turges- 
cence of the blood. 

1 1 29.] These are the means to be employed for prevent- 
ing the apoplexv which might arise from a plethoric state 
of the vessels of the brain ; and if, at the same time, great 
care is taken to avoid the exciting causes (1097.) these 
means will be generally successful. 

In the cases proceeding from other causes (1114.) as 
their application is so immediately succeeded by the dis- 
ease, they hardly allow any opportunity for prevention. 

1 130.] For the cure of apoplexies from internal causes, 
and which I suppose to be chiefly those from compression, 
the usual violence and fatality of it require that the proper 
remedies be immediately and largely employed. 

The patient is to be kept as much as possible in some- 
what of an erect posture, and in cool air; and therefore 
neither in a warm chamber, nor covered with bed clothes, 
nor surrounded with a crowd of people. 

1131.] In all cases of a full habit, and where the disease 
has been preceded bv marks of a plethoric state, blood-let- 
ting is to be immediately employed, and very largely. In 
my opinion, it will be most effectual when the blood is tak- 
en from the jugular vein; but, if that cannot be properly 
done, it may be taken from the arm. The opening of the 
temporal artery, when a large branch can be opened, so as 
suddenly to pour out a considerable quantity of blood, may 
also be an effectual remedy; but in execution, it is more 
uncertain, and may be inconvenient. It may be in some 
measure supplied, bv cupping and scarifying on the tem- 
ples or hind-head This, indeed, should seldom be omitted ; 
and these scarifications are always preferable to the applica- 
tion of leeches. 

With respect to every mode of blood-letting, this is to 



356 PRACTICE OF PHYSIC. 

be observed, that when in any case of apoplexy, it can be 
perceived that one side of the body is more affected with the 
loss of motion than the other, the blood-letting, if possible 
should be made on the side opposite to that most affected.* 

1132.] Another remedy to be employed is purging, to be 
immediately attempted by acrid glysters ;f and, at the same 
time, if any power of swallowing remain, by drastic pur- 
gatives given by the mouth. These, however, lest they 
may excite vomiting, should be given in divided portions at 
proper intervals.^ 

1133.] Vomiting has been commended by some practi- 
tioners and writers: but, apprehending that this might im- 
pel the blood with too much violence into the vessels of the 
head, I have never employed it. 

1134.] Another remedy to be immediately employed is 
blistering ; and I judge that this is more effectual when ap- 
plied to the head, or near to it, than when it is applied to 
the lower extremities. This remedy I do not consider as a 
stimulant, or capable of making any considerable revulsion ; 
but, applied to the head, I suppose it useful in taking off 
the hemorrhagic disposition so often prevailing there. 

1135.] It has been usual with practitioners, together with 

* Dissections shew that the congestions producing apoplexy are always on the side not affect- 
ed ; and hence the propriety of the direction. 
+ Acrid glysters arc, 

R. Elect, lenitiv. §i. 

Sal. cathartic, amar. oiiss. 

Aq. tepid. §xi. 

M. f. Enema. 
R. Sapon. alb. Siss. 

Solve in aq. tepid. %x. ; cui adde 

Syr. e spina cerv. §ii. 

M. f. Enema. 
R. Pulp, colocynth. 3iii. 

Coque per horse quadrantem in aq. font, 
q. s. ad colaturas §xii. ; cui adde 

Ol. olivar. 51. 

M. f. Enema. 

t The drastic purges are, in thjesc cases, to be given in draughts, rather than in pills or bi>- 
luses. The following form may be used : 

R. Pulv. jalap. 3i- 
Rad. zinzib. 9i. 
Infus. sem. lini Biii. 
M. 

The dose of this mixture is two spoonfuls every two hours till it operate, or we may use one 
*f the formula mentioned in the note on article 1079. especially the last, repeating it ever)' 
.two hours till it produces an effect. 



PRACTICE OF PHYSIC. 357 

the remedies already mentioned, to employ stimulants of 
various kinds ; but I am disposed to think them generally 
hurtful; and they must be so, •wherever the fulness of the 
vessels, and the impetus of the blood in these, is to be dimi- 
nished. Upon this principle it is therefore agreed, that 
stimulants are absolutely improper in what is supposed to be 
a sanguine apoplexy ; but they are commonly supposed to 
be proper in the serous. If, however, we be right in al- 
ledging that this also commonly depends upon a plethoric 
state of the blood-vessels of the brain, stimulants must b«k 
equally improper in the one case as in the other. 

1136.] It maybe argued from the almost universal em- 
ployment of stimulants, and sometimes with seeming ad- 
vantage, that they may not be so hurtful as my notions of 
the causes of apoplexy lead me to suppose. But this ar- 
gument is, in several respects, fallacious; and particularly 
in this, that in a disease which, under every management, 
often proceeds so quickly to a fatal termination, the effects 
of remedies are not to be easily ascertained. 

1137.] I have now mentioned the several remedies which 
I think adapted to the cure of apoplexy arising from com- 
pression, and should next proceed to treat of the cure of 
apoplexy arising from those causes that directly destroy the 
mobility of the nervous power. But many of those causes 
arc often so powerful, and thereby so suddenly fatal in their 
effects, as hardly to allow of time for the use of remedies; 
and such cases, therefore, have been so seldom the subjects 
of practice, that the proper remedies are not so well ascer- 
tained as to enable me to say much of them here. 

1138.] When, however, the application of the causes, 
(1114.) is not so powerful as immediately to kill, and in- 
duces only an apoplectic state, some efforts are to be made 
to obviate the consequences, and to recover the patient ; 
and even in some cases where the causes referred to, from 
the ceasing of the pulse and of respiration, and from a 
coldness coming upon the body, have induced an appear- 
ance of death ; yet, if these appearances have not continued 
long, there may be means of recovering the persons to life 
and health. I cannot, indeed, treat this subject complete- 
ly ; but for the cure of apoplexy from several of the causes 
mentioned (1 114.) shall offer the following general directions. 

1. When a poison capable of producing apoplexy has 
been recently taken into the stomach, if a vomiting spon- 
taneously arises, it is to be encouraged ; or, if it does not 



358 PRACTICE OF PHYSIC. 

spontaneously come on, a vomiting is to be immediately 
excited by art, in order that the poison may be thrown out 
as quickly as possible. If, however, the poison has been 
taken into the stomach long before its effects have appear- 
ed, wejulgethat, upon their appearance, the exciting of 
vomiting will be useless, and may perhaps be hurtful. 

2. When the poison taken into the stomach, or otherwise 
applied to the body, has already induced an apoplectic 
state, as those causes do commonly at the same time occa- 
sion a stagnation or slower motion of the blood in the ves- 
sels of the brain and of the lungs, so it will generally be 
proper to relieve this congestion by taking some blood from 
the jugular vein, or from the veins of the arm. 

3. Upon the same supposition of a congestion in the brain 
or lungs, it will generally be proper to relieve it by means 
of acrid glysters producing some evacuation from the in- 
testines. 

4. When these evacuations by blood-letting and purging 
have been made, the various stimulants which have been 
commonly proposed in other cases of apoplexy, may be 
employed here with more probability and safety.* One of 
the most effectual means of rousing apoplectics of this kind, 
seems to be throwing cold water on several parts of the bo- 
dy, or washing the body all over with it. 

5. Although the poison producing apoplexy happens to 
be so powerful as very soon to occasion the appearances of 
death above-mentioned ; yet if this state has not continued 
long, the patient may often be recoverable ; and the reco- 
very is to be attempted by the same means that are directed 
to be employed for the recovery of drowned persons, and 
which are now commonly known. 



CHAPTER II. 

OF PALSY. 

1139.] "O^LSY i s a disease consisting in a loss of the 
XT power of voluntary motion, but affecting cer- 
tain parts of the body only, and by this it is distinguished 
from apoplexy. (1093.) One of the most frequent forms of 

* The stimulants are various according to the various parts of the body to which they are ge- 
nerally applied, as volatile and vinou spirits, or vinegar, to the nose and temples; acrid es- 
sential oils, mued with thrice their weight of hogs-lard, to the breast and back; blisters, hot 
sinapisms, and warm fomentations, with norse-radish, lo the extremities ; frictions wad warm 
brushes ; the actual cautery to the soles of the feet, and palms of the hands, will] sever-1 
others, which are nure particularly described in the notes on article 1160. et se}. 



PRACTICE OF PHYSIC. 359 

palsy is when it affects the whole of the muscles on one side 
of the body ; and then the disease is named a Hemiplegia. 

1 1 40.] The loss of the power of voluntary motion may 
be owing either to a morbid affection of the muscles cr or- 
gans of motion, by which they are rendered unfit for mo- 
tion ; or to an interruption of the influx of the nervous 
power into them, which is always necessary to the motions of 
those that are under the power of the will. 1 he disease, 
from the first of these causes, as consisting in an organic 
and local affection, we refer entirely to the class of local 
diseases. I am here to consider that disease only which de- 
pends upon the interrupted influx of the nervous power ; 
and it is to this disease alone I would give the appellation of 
Palsy. A disease depending on an interrupted influx of 
the nervous power, may indeed often appear as merely* a 
local affection ; but as it depends upon an affection of the 
most general powers of the system, it cannot be properly 
separated from the systematic affections. 

1141.] In palsy, the loss of motion is often accompanied 
with the loss of sense ; but as this is not constantly the case, 
and as therefore the loss of sense is not an essential symp- 
tom of palsy, I have not taken it into my definition (1139.) 
and I shall not think it necessary to take any further notice 
of it in this treatise ; because, in so far as it is in any case a 
part of the paralytic affection, it must depend upon the 
same causes, and will be cured also by the very same reme- 
dies, as the loss of motion. 

1 142.] The palsy then, or loss of motion, which is to be 
treated of here, may be distinguished as of two kinds ; one 
of them depending upon an affection of the origin of the 
nerves in the brain, and the other depending upon an affec- 
tion of the nerves in some part of their course between the 
brain and the organs of motion. Of the latter, as appear- 
ing in a very partial affection, I am not to speak particularly 
here ; I shall only treat of the more general paralytic affec- 
tions, and especially of the hemiplegia (1139.) At the 
same time I expect, that what I shall say upon this subject 
will readily apply to both the pathology and practice in the 
cases of affections more limited. 

1143.] The hemiplegia (1139.) usually begins with, or 
follows, a paroxysm of apoplexy ; and when the hemiple- 
gia, after subsisting for some time becomes fatal, it is com- 
monly by passing again into the state of apoplexy. The 
relation therefore or affinity between the two diseases, is 



360 PRACTICE OF PHYSIC. 

sufficiently evident ; and is further strongly confirmed by 
this, that the hemiplegia comes upon persons of the same 
constitution (1094.) and is preceded by the same symptoms 
.(1097.) that have been taken notice of with respect to 
apoplexy. 

1 144.] When a fit of apoplexy has gone off, and there 
remains a state of palsy appearing as a partial affection on- 
ly, it might perhaps be supposed that the origin of the 
nerves is in a great measure relieved ; but in so far as com- 
monly there still remain the symptoms of the loss of me- 
mory, and of some degree of fatuity, these, 1 think, show 
that the organ of intellect, or the common origin of the 
nerves, is still considerably affected. 

1145.] Thus, the hemiplegia, from its evident connec- 
tion with, and near relation to apoplexy, may be properly 
considered as depending upon like causes ; and conse- 
quently either upon a compression preventing the flow of 
the nervous power from the brain into the organs of mo- 
tion, or upon the application of narcotic or other powers 
(1114.) rendering the nervous power unfit to flow in the 
usual and proper manner. 

1146.] We begin with considering the cases depending 
upon compression. 

The compression occasioning hemiplegia may be of the 
same kind, and of all the different kinds that produce apo- 
plexy ; and therefore either from tumor, over-distention, 
or effusion. The existence of tumor giving compression, 
may often be better discerned in the case of palsy than in 
that of apoplexy, as its effects often appear at first in a 
very partial affection. 

1147.] The other modes of compression, that is, of 
over-distention and effusion, may, and commonly do, take 

Elace, in hemiplegia : and when they do, their operation 
ere differs from that producing apoplexy, by its effects 
being partial, and on one side of the body only. 

It may seem difficult to conceive that an over-distention 
«an take place in the vessels on one side of the brain only ; 
but it may be understood : and in the case of a palsy which is 
both partial and transitory, it is perhaps the only condition 
of the vessels of the brain that can be supposed. In a he- 
miplegia, indeed, which subsists for any length of time, 
there is probably always an effusion, either sanguine or se- 
fous : but it is likely that even the latter must be supported 
hy a remaining congestion in the blood-vessels. 



PRACTICE OF PHYSIC. 361 

1 148.] That a sanguine effusion can happen without be- 
coming very soon general, and thereby occasioning apoplexy 
and death, may also seem doubtful : but dissections prove 
that in fact it does happen, occasioning palsy only ; though 
it is true, that this more commonly depends upon an effu- 
sion of serous fluid, and of this only. 

1149.] Can a palsy, occasioned by a compression re- 
main, though the compression be removed ?* 

1150.] From what has been said, (1143.) it will be ob- 
vious, that the hemiplegia may be prevented by all the se- 
veral means proposed (1124. et seq.) for the prevention of 
apoplexy. 

1151.] Upon the same grounds, the cure of palsy must 
be very much the same with that of apoplexy ( 1 129. et seq.) 
and when palsy has begun as an apoplexy, it is presumed, 
that, before it is to be considered as palsy, all those several 
remedies have been employed. Indeed, even when it hap- 
pens that on the first attack of the disease the apoplectic 
state is not very complete, and that the very first appear- 
ance of the disease is as a hemiplegia, the affinity between 
the two diseases (1143.) is such as to lead to the same re- 
medies in both cases. This is certainly proper in all those 
cases in which we can with much probability impute the 
disease to compression ; and it is indeed seldom that a he- 
miplegia from internal causes comes on but with a conside- 
rable affection of the internal, and even of the external 
senses, together with other marks of a compression of the 
origin of the nerves. 

1152.] Not only, however, where the disease can be 
imputed to compression, but even where it can be imputed 
to the application of narcotic powers, if the disease come 
on with the appearances mentioned at the end of the last 
paragraph, it is to be treated in the same manner as an apo- 
plexy by 1130—1138. 

1153.] The cure of hemiplegia, therefore, on its first at- 
tack, is the same, or nearly the same, with that of apoplexy: 
and it seems requisite that it should be different onlv, I. 
When the disease has subsisted for some time ; 2. When 
the apoplectic symptoms, or thosef marking a considerable 
compression of the origin of the nerves, are removed ; and 
particularly, 3. When there are no evident marks of com- 

• This question may be answered in the affirmative; because the structure of the nerve may 
i, and the nerve may therefore remain impervious to the nervous 
inriucni'i nprcssion has been removed. 

+ The moat infallible oi these marks is the intellectual faculties nut returning. 

3 A 



362 PRACTICE OF PHYSIC. 

pression, and it is at the same time known that narcotic 
powers have been applied. 

1154.] In all these cases, the question arises, Whether 
stimulants may be employed, or how far the cure may be 
entirely trusted to such remedies ? Upon this question, with 
respect to apoplexy, I have offered my opinion in 1135. 
And, with respect to hemiplegia, I am of opinion, that sti- 
mulants are almost always equally dangerous as in the cases 
of complete apoplexy ; and particularly, 1. In all , the cases 
of hemiplegia succeeding to a paroxysm of complete apo- 
plexy ; 2. In all the cases coming upon persons of the tem- 
perament mentioned in 1094, and after the same antecedents 
as those of apoplexy, 11 15, and 3. In all the cases coming 
on with symptoms of apoplexy from compression. 

1155.] It is, therefore, in the cases 1153, only, that sti- 
mulants are properly admissible : and even in the two first 
of these cases, in which a plethoric state of the blood-vessels 
of the brain may have brought on the disease, in which a 
disposition to that state may still continue, and in which* 
even some degree of congestion may still remain, the use of 
stimulants must be an ambiguous remedy ; so that perhaps 
it is in the third of these cases only that stimulants are clear- 
ly indicated and admissible. 

1156.] These doubts with respect to the use of stimu- 
lants, may perhaps be overlooked or disregarded by those 
who alledge that stimulants have been employed with ad- 
vantage even in those cases 1154, in which I have said they 
ought to be avoided. 

1157.] To compromise this contrariety of opinion, I 
must observe, that even in the cases of hemiplegia depend- 
ing upon compression, although the origin of the nerves be 
so much compressed an to prevent so full a flow of the ner- 
vous power as is necessary to muscular motion, }^et it ap- 
pears from the power of sense still remaining, that the 
nerves are, to a certain degree, still pervious ; and there- 
fore it is possible that stimulants applied, may excite the 
energy of the brain so much,, as in some measure to force 
open the compressed nerves, and to show some return of 
motion in paralytic muscles. Nay, further, it may be al- 
lowed, that if these stimulants be such as act more upon the 
nervous than upon the sanguiferous system, they may pos- 
siblv be employed without any very hurtful consequence 

1 158.] But still it will be obvious, that although certain 
stimulants act chiefly upon the nervous system, yet they 



PRACTICE OF PHYSIC. 363 

also act always in some measure upon the sanguiferous ; so 
that, when they happen to have the latter effect in any con- 
siderable degree, they may certainly do much harm ; and 
in a disease which they do not entirely cure, the mischief 
arising from them may not be discerned. 

1159.] Whilst the employment of stimulants is so often 
an ambiguous practice, we may perhaps go some length to- 
wards ascertaining the matter, by considering the nature of 
the several stimulants which may be employed, and some 
of the circumstances of their administration. With this 
view, therefore, I shall now mention the several stimulants 
that have been commonly employed, and offer some re- 
marks upon their nature and use. 

1 160.] They are in the first place to be distinguished as 
external or internal. Of the first kind, we again distinguish 
them as they are applied to particular parts of the bouy on- 
Jy, or as they are more generally applied to the whole sys- 
tem. Of the first kind are, 

1 . The concentrated acids of vitriol or nitre ; involved 
however, in oily or unctuous substances, which may obviate 
their corrosive, without destroying their stimulant power.* 

2. The volatile alkaline spirits, especially in their cau- 
stic state ; but involved also in oils, for the purpose just 
now mentioned. f 

3. The same volatile spirits are frequently employed by 
being held to the nose, when they prove a powerful stimu- 
lus to the nervous system ; but it is at the same time pro- 
bable, that they may also prove a strong stimulant to the 
blood-vessels of the brain. 

4. A brine or strong solution of sea-salt. X 

* RubifacierU ointments are compositions like tbe following t 

R. Azung. porcin. 5H. 

Acid vitriol. 3i. 

M. Oi, 
ft. Unguent, basilic, flay. SiL 

Acid, vitriol. 3i. 

M. 

They soon redden and inflame the skin ; and, when this effect is produotd, they must kc 
Okcn off, and the part anointed with common Ointment, or with oil. 
t The Lmimciua volatilia or the Pharmacopoeias are not so strong as the following : 

R. Alkal. volatil. caustic. I'u 
01. olivar. Sii* 
M. 

In the new London Pharmacopoeia this composition is called Linimentum Ammonia- Fortius. 
brlna mat remains in the talt-pana, after the common sait is crystallized, is the mo.t 
il ol these Unny stimulants. It rs called in Edinburgh Oil ol ialf. 



364 PRACTICE OF PHYSIC. 

5. The essential oils of aromatic plants,* or of their parts. 

6. The essential oils of turpentine, or of other such re- 
sinous substances. 

7. The distilled oils of amber, or of other bituminous 
fossils. f 

8. The rectified empyreumatic oils of animal or vegeta- 
ble substances.;]; 

9. Various vegetable acrids, particularly mustard. || 

10. The acrid matter found in several insects, particu- 
larly canthandes.§ 

Some of these stimulants may be either applied in sub- 
stance ; or may be dissolved in ardent spirits, by which 
their stimulant power may be increased, or more conve- 
niently applied. 

1161.] The greater part of the substances now enume- 
rated show their stimulant power by inflaming the skin of 
the part to which they are applied ; and when their appli- 
cation is so long continued as to produce this effect, it in- 
terrupts the continuance of their use ; and the inflammation 
of the part does not seem to do so much good as the fre- 
quent repetition of a more moderate stimulus. 

f!62.] Analogous to these stimulants is the stinging of 
nettles, which has been frequently commended. 

Among the external stimulants, the mechanical one of 
friction with the naked hand, the flesh-brush, or flannel, is 
justly to be reckoned. Can the impregnation of the flan- 
nels to be employed, with the fumes of burning mastic, 
olibanum, &c. be of any service ?^[ 

1163.] With respect to the whole of these external sti- 
mulants, it is to be observed, that they affect the part to 

* The Ol. Origani is generally used. It ought to be mixed with some unctuous oil, as in the 
following formula : 

R. 01. origan. 3"- 
Azung. porcin. Siv. 
M. 

The aromatic oil; dissolved in spirit make an elegant application, but the distilled spirits of 
the plants themselves are more in use. 

+ They are generally used with hogs-lard, in the proportion of eight times their quantity of 
lard. Some practitioners, however, take only twice the quantity of lata; but they are not so 
effectual ai v>me of the rubitacients above enumerated. 

t The use of these eiiipyreumauc oils is not so frequent now as formerly ; they are extremely 
acrid, and, if not used with caution, o'ten corrode the skin. 

II The lorm, in winch flour of mustard is used, is called a Sinapism. It is mixed with an equal 
quaniit. of bread crumb or oat-meal, made into apastewiih vinegar. Some practitioners add 
bruised garhc, in the proportion of one fourth of the quantity of ngustard ; but it is extreniely 
offensive, and the cataplasm, without it, answers sufficiently well. 

$ rnese insects are ihe basis of the blistering plaisters and ointments. 

H Manv practitioners have thought that such impregnations have b^en of singular service. The 
fumes of most of these re ins are either Mowers, as they are called in the shops, or essential oils, 
both of which are stimulating, and may therefore be supposed to be active. The impregnating 
flannels or flesh-brushes with flour of mustard is often u>ed, and assiits considerably in bringing 
on an inUainmation. 



PRACTICE OF PHYSIC. 36 5 

'Which they are applied much more than they do the whole 
system, and they are therefore indeed safer in ambiguous 
cases ; but, for the same reason, they are of less efficacy 
in curing a general affection. 

1164.] The external applications which may be applied 
to affect the whole system, are the powers of heat and cold, 
and of electricity. 

Heat, as one of the most powerful stimulants of the ani- 
mal economy, has been often employed in palsies, especi- 
aliy by warm bathing. But as, both by stimulating the so- 
lids and rarefying the fluids, this proves a strong stimulus 
to the sanguiferous system, it is often an ambiguous reme- 
dy ; and has frequently been manifestly hurtful in palsies 
depending upon a congestion of blood in the vessels of the 
brain. The most certain and therefore the most proper 
use of warm bathing in palsies, seems to be in those that 
have been occasioned by the application of narcotic pow- 
ers. Are the natural baths more useful by the matters with 
which they may be naturally impregnated?* 

1 165.] Cold applied to the body for any length of time, 
is always hurtful to the paralytic persons; but if it be not 
very intense, nor the application long continued, and if at 
the same time the body be capable of a brisk reaction, such 
an application of cold is a powerful stimulant of the whole 
system, and has often been useful in curing palsy. But, 
if the power of reaction in the body be weak, any appli- 
cation of cold may prove very hurtful. f 

1166.] Electricity, in a certain manner applied, is cer- 
tainly one of the most powerful stimulants that can be em- 
ployed to act upon the nervous system of animals; and 
therefore much has been expected from it in the cure of 
palsy. But, as it stimulates the sanguiferous as well as thu 
nervous system, it has been often hurtful in palsies depend- 
ing upon a compression of the brain ; and especially when 
it has been so applied as to act upon the vessels of the head. 
It is safer when its operation is confined to particular parts 
somewhat remote from the head ; and, further, as the ope- 
ration of electricity, when very strong can destroy the mo- 

* The natural baths contain so small a quantity of impregnating substances as induces us to 
that ihey cannot have any beneficial powers superior to those of ordinary waim bail's. 
' of warm baths ought not to be promiscuous In cases of palsies, arising from co- 
ns, as the fumes of arsenic or inelals, and their ores, the warm baths seldom tail of 
procuring relief; and some instances have been given by authors of complete cures having been 
'I by the u e of Ijath- 
+ Hie very (real uncertainty of ihe power of reaction always makes the application of cold a 
tbtful remedy ; and, as it is evidently hurtful wherever the reaction is weak, it ough; 
to bo u»ed with e.tucmc caution. 



S66 PRACTICE OF PHYSIC. 

bility of the nervous power, I am of opinion, that it is 
always to be employed with caution, and that it is only 
safe Avhen applied with moderate force, and when confined 
to certain parts of the body remote from the head. It is 
also my opinion, that its good effects are to be expected 
from its repetition rather than from its force, and that it is 
particularly suited to the cure of those palsies which have 
been produced by the application of narcotic powers. 

1167.] Amongst the remedies of palsy, the use of exer- 
cise is not to be omitted. In a hemiplegia, bodily exer* 
cise cannot be employed; and in a more limited affection, 
if depending upon a compression of some part of the brain, 
it would be an ambiguous remedy : but, in all cases where 
the exercise of gestation can be employed, they are pro- 
per; as, even in cases of compression, the stimulus of 
such exercise is moderate, and therefore safe; and, as it 
always determines to the surface of the body, it is a reme- 
dy in all cases of internal congestion. 

1168.] The internal stimulants employed in palsy are 
rarious, but chiefly the following. 

1. The volatile alkaline salts, or spirits, as they are 
called, are very powerful and diffusive stimulants, operat- 
ing especially on the nervous system ;* and even although 
they operate on the sanguiferous, yet, if given in frequent- 
ly repeated small rather than in large doses, their opera- 
tion being transitory, is tolerably safe. 

2. The vegetables of the class named Tetradynamia, are 
many of them powerful diffusive stimulants; and at the 
same time, as quickly passing out of the body, and there- 
fore a transitory operation, they are often employed with 
safety.f As they commonly prove diuretic, they may in 
this way also be of service in some cases of serous palsy. 

3. The various aromatics, whether employed in sub- 
stance, in tincture, or in their essential oils, are often pow- 

* Of these there are several formula; in the shops, as Spiritus volatilis aromaticus, Spiritus vo- 
latilis oleosus, Spiritus salinus aromaticus. Their dose is from ten to sixty drops. The Eau de 
Luce ought to be mentioned here, though it is seldom used internally, but only for smelling to, 
as it isextremely penetrating. It is prepared thus: Mix together in a retort forty drops of rec- 
tified oil of amber, an ounce of rectified spirit of wine, and twelve ounces of the strongest 
caustic volatile alkali. They must be distilled with a very moderate fire. It is seldom limpid, 
but has a milky appearance, owing to the imperfect solution of the oil iu the spirit; and, if the 
alkali be nut very < austic, scarcely any of the oil is dissofVed. 

+ White mustard seeds rttf Jje given whole, in the quantity of two lea-spoonfuls in a half 
tea-cupful of cold water. They ought to be swallowed whole, that their acrid taste may not be 
perceived. 'Tnfc dose may Ue repeated twice Or thftc e a d^y. Horse-radish is another plant 
of this class of vegetables thai has been much Items' nreuded ; it nrist be given in a cold watery 
infusion, or in an infusion in ale. 1 he sew vy-gra s is another of ihe same class; it may be eaten 
raw, or we may give forty or fifty dr. . either on a piece of sugar, 

cr mixed' with half announce - of syrup, four or five times a-riay. 1 his spirit ought to be kept 
well corked, a: it soon loses all its activity, if it be exposed to the air. 



PRACTICE OF PHYSIC. 367 

erful stimulants; but being more adhesive and inflamma- 
tory than those last mentioned, they are therefore, in all 
ambiguous cases, less safe.* 

4. Some other acrid vegetables have been employed; 
but we are not well acquainted with their peculiar virtues, 
or proper use. 

5. Some resinous substances, as guaiacum, and the te- 
rebinthinate substances, or their essential oils, have been 
with some probability, employed; but they are apt to be- 
come inflammatory. Decoctions of guaiacum, and some 
other sudoritics, have been directed to excite sweating by 
the application of the fumes of burning spirit of wine in the 
laconicum, and have in that way been found useful. 

6. Many of the fetid antispasmodic medicines have been 
frequently employed in palsy; but I do not perceive in 
what manner they are adapted to the cure of this disease, 
and 1 have not observed their good effects in any case 
of it. 

1. Bitters and the Peruvian bark, have, also been em- 
ployed; but with no propriety or advantage that I can 
perceive. f 

1169.] With respect to the whole of these internal sti- 
mulants, it is to be observed, that they seldom prove very 
powerful; and wherever there is any doubt concerning the 
nature or state of the disease, they may readily do harm, 
and are often therefore of ambiguous use. 

* The aromatics best adapted for stimulating, in these cases, are such as Linne calls Spirantia - T 
the chief of ihem are, Marum, Rosemary, Lavender, &c. Their spirituous waters are much 
more efficacious itian the plants m substance, or in any other form ; and their efficacy is consi- 
derably incieibed by uniling them to volatile spirits, as in some of the formula? mentioned in 
Uie first note on this article. 

+ In some cases, paralytic patients, for want of exercise, sink into a state of debility, with 
loss of appetite, and consequent emaciation, in which bitters, Peruvian bark, and other tonics 
.ac frequent^! of some advantage. 



368 PRACTICE OF PHYSIC. 



BOOK II. 

OF ADYNAMIC ; OR DISEASES CONSIST- 
ING IN A WEAKNESS OR LOSS OF MO- 
TION IN EITHER THE VITAL OR NA- 
TURAL FUNCTIONS. 



CHAPTER I. 
OF SYNCOPE, OR FAINTING. 

1170.] r I ^HIS is a disease in which the action of the 
JL heart and respiration become considerably 
weaker than usual, or in which for a certain time these 
functions cease altogether. 

1171.] Physicians having observed that this affection oc- 
curs in different degrees, have endeavored to distinguish 
these by different appellations: but as it is not possible to 
ascertain these different degrees with any precision, so 
there can be no strict propriety in employing those differ- 
ent names; and I shall here comprehend the whole of the 
affections of this kind under the title of Syncope. 

1172.] This disease sometimes comes on suddenly to a 
considerable degree, but sometimes also it comes on gradu- 
ally; and in the latter case, it usually comes on with a 
sense of languor, and of anxiety about the heart, accom- 
panied at the same time, or immediately after with some 
giddiness, dimness of sight, and sounding in the ears. To- 
gether with these symptoms, the pulse and respiration be- 
come weak; and often so weak, that the pulse is scarcely 
to be felt, or the respiration to be perceived; and some- 
times these motions, for a certain time, cease altogether. 
While these symptoms take place, the face and whole sur- 
face of the body become pale, and more or less cold ac- 
cording to the degree and duration of the paroxvsm. Ve- 
ry commonly at the beginning of this, and during its con- 
tinuance, a cold sweat appears, and perhaps continues, 
on the forehead , as well as on some other parts of the bo- 
dy. During the paroxysm, the animal functions, both of 



PRACTICE OF PHYSIC. 369 

sense and motion, are always in some degree impaired, and 
very often entirely suspended. A paroxysm of syncope is 
often, after some time, spontaneously recovered from ; and 
this recovery is generally attended with a sense of much 
anxiety about the heart. 

Fits of syncope are frequently attended with, or end in, vo- 
miting ; and sometimes with convulsions, or an epileptic fit. 

1173.] These are the phenomena in this disease; and 
from every view of the greatest part of them, there cannot 
be a doubt that the proximate cause of this disease is a very- 
weak or total ceasing of the action of the heart. But it 
will be a very difficult matter to explain in what manner 
the several remote causes operate in producing the proxi- 
mate cause. This, however, I shall attempt, though with 
that diffidence which becomes me in attempting a subject 
that has not hitherto been treated with much success. 

1174.] The remote causes of syncope may, in the first 
place, be referred to two general heads. The one is, of 
those causes existing and acting in the brain, or in parts of 
the body remote from the heart, but acting upon it by the 
intervention of the brain. The other general head of the 
remote causes of syncope, is of those existing in the heart 
itself, or in parts very immediately connected with it, and 
thereby acting more directly upon it in producingthis disease. 

1 175.] In entering upon the consideration of the first set 
of those causes (1174.) I must assume a proposition which 
I suppose to be fully established in physiology. It is this : 
That, though the muscular fibres of the heart be endowed 
with a certain degree of inherent power, they are still, for 
such action as is necessary to the motion of the blood, very 
constantly dependent upon a nervous power sent into them 
from the brain.* At least this is evident, that there are cer- 
tain powers acting primarily, and perhaps only in the brain, 
which influence and variously modify the action of the 
heart. I suppose, therefore, a force very constantly dur- 
ing life exerted in the brain, with respect to the moving 
fibres of the heart, as well as of every part of the body ; 
which force I shall call the energy of the brain : and which 
I suppose may be, on different occasions, stronger or weak- 
er with respect to the heart. 

• The author here differs somewhat in opinion from physiologists. He allows, indeed, that 
the heart possesses a vis insita in a certain decree, but he will not allow this vis insita to be suf- 
ficiently strong for carrying on the circulation; and he thinks that some energy must be i inputted 
to the heart from the brain, in order to enable that important -.niisile to perform its office. In 
support of this opinion, we have a plain fact, which the author might have adduced, viz. that a 
ligature on the nerves going to the heart immediately stops its motion*. 

3b 



370 PRACTICE OF PHYSIC. 

1176.] Admitting these propositions, it will be obvious., 
that if I can explain in what manner the first set of remote 
causes (1174.) diminish the energy of the brain, I shall at 
the same time explain in what manner these causes occasion 
a syncope. 

1177.] To do this, I observe, that one of the most evi- 
dent of the remote causes of syncope is a hemorrhagy, of 
an evacuation of blood, whether spontaneous or artificial. 
And as it is very manifest that the energy of the brain de- 
pends upon a certain fulness and tension of its blood-vessels, 
for which nature seems to have industriously provided by 
such a conformation of those blood-vessels as retards the 
motion of the blood both in the arteries and veins of the 
brain ; so we can readily perceive, that evacuations of blood, 
by taking off the fulness and tension of the blood-vessels of 
the brain, and thereby diminishing its energy with respect 
to the heart, may occasion a syncope. In many persons, 
a small evacuation of blood will have this effect ; and in 
such cases there is often a clear proof of the manner in 
which the cause operates, from this circumstance, that the 
effect can be prevented by laying the body in a horizontal 
posture ; which, by favoring the afflux of the blood by the 
arteries, and retarding the return of it by the veins, pre- 
serves the necessary fulness of the vessels of the brain. 

It is farther to be remarked here, that not only an evacu- 
ation of blood occasions syncope, but that even a change in 
the distribution of the blood, whereby a larger portion of it 
flows into one part of the system of blood-vessels, and con- 
sequently less into others, may occasion a syncope. It is 
thus I explain the syncope, that readily occurs upon the eva- 
cuation of hydropic waters, which had before filled the cavi- 
ties of the abdomen or thorax. It is thus also I explain the 
syncope that sometimes happens on blood-letting, but which 
does not happen till the ligature which had been employed is 
untied, and admits a larger afflux of blood into the blood- 
vessels of the arm. Both these cases of syncope show, that 
an evacuation of blood does not always occasion the disease 
by any general effect on the whole system, but often merely 
by taking off the requisite fulnels of the blood-vessels of 
tne brain. 

1178.] The operation of some others of the remote cau- 
ses of syncope, may be explained on the following princi- 
ples. Whilst the energy of the brain is, upon different oc- 
casions, manifestly stronger or weaker, it seems to be with 



PRACTICE OF PHYSIC. 37! 

this condition, that a stronger exertion of it is necessarily 
followed by a weaker state of the same. It seems to depend 
upon this law in the constitution of the nervous power, 
that the ordinary contraction of a muscle is always alter- 
nated with a relaxation of the same ; that, unless a contrac- 
tion proceeds to the degree of spasm, the contracted state 
cannot be long continued : and it seems to depend upon the 
same cause that the voluntary motions, which always require 
an unusual increase of exertion, occasion fatigue, debility, 
and at length irresistible sleep. 

From this law, therefore, of the nervous power, we may 
understand why a sudden and violent exertion of the ener- 
gy of the brain is sometimes followed by such a diminution 
of it as to occasion a syncope; and it is thus I suppose that 
a violent fit of joy produces syncope, and even death. It 
is upon the same principle also, I suppose, that an exqui- 
site pain may sometimes excite the energy of the brain more 
strongly than can be supported, and is therefore followed 
by such a diminution as must occasion fainting. But the 
effect of this principle appears more clearly in this, that a 
fainting readily happens upon the sudden remission of a 
considerable pain ; and thus I have seen a fainting occur 
upon the reduction of a painful dislocation. 

1179.] It seems to be quite analogous when a syncope 
immediately happens on the finishing of any great and long- 
continued effort, whether depending on the will, or upon 
a propensity ; and in this way a fainting sometimes happens 
to a woman on the bearing of a child. This may be well 
illustrated by observing, that in persons already much weak- 
ened, even a very moderate effort will sometimes occasion 
fainting. 

1180.] To explain the operation of some other causes 
of syncope, it may be observed, that as the exertions of 
the energy of the brain are especially under the influence 
of the will, so it is well known that those modifications of 
the will which are named Passions and Emotions, have a 
powerful influence on the energy of the brain in its action 
upon the heart, either in increasing or diminishing the force 
of that energy. Thus, anger has the former, and fear the 
latter effect; and thence it may be understood how terror 
often occasions a syncope sometimes of the most violent 
kind, named Asphyxia, and sometimes death itself. 

1181.] As, from what I have just mentioned, it appears, 
that the emotions of desire increase, and those of aversion 



372 PRACTICE OF PHYSIC. 

diminish the energy of the brain ; so it may be understood, 
how a strong aversion, a horror, or the feeling which arises 
upon the sight of a very disagreeble object, may occasion 
fainting. As an example of this, I have known more than 
one instance of a person's fainting at the sight of a sore in 
another person. 

1182.] To this head of horror and disgust, I refer the 
operation of those odours which in certain persons occa- 
sion syncope. It may be supposed, that those odours are 
endowed with a directly sedative power, and may thereby 
occasion syncope; but they are, many of them, with res- 
pect to other persons, evidently of a contrary quality; and 
it appears to me, that those odours occasion syncope only 
in those persons to whom they are extremely disagreeable. 

1183.] It is, however, very probable, that among the 
causes of syncope, there are some which, analogous to all 
those we have already mentioned, act by a directly sedative 
power: And such may either be diffused in the mass of 
blood, and thereby communicated to the brain; or may 
be onlv taken into the stomach, which so readily and fre- 
quently communicates its affections to the brain. 

1184.] Having now enumerated, and, as I hope, ex- 
plained the most part of the remote causes of syncope, that 
either operate immediately upon the brain, or whose ope- 
ration upon other parts of the body is communicated to 
the brain, it is proper to observe, that the most part of 
these causes operate upon certain persons more readily and 
more powerfully than upon others; and this circumstance, 
which may be considered as the predisponent cause of syn- 
cope, deserves to be inquired into. 

It is in the first place, obvious, that the operation of 
some of those causes depends entirely upon an idiosyncrasy 
in the persons upon whom they operate; which, however, 
I cannot pretend to explain. But, in the next place, with 
respect to the greater part of the other causes, their effects 
seem to depend upon* a temperament Avhich is in one de- 
gree or other in common to many persons. This tempe- 
rament seems to consist in a great degree of sensibility and 
mobility, arising from a state of debility, sometimes de- 
pending upon original conformation, and sometimes pro- 
duced by accidental occurrences in the course of life, 

1185,] The second set of the remote causes of syncope 
(1174.) or those acting directly upon the heart itself, arc 
certain organic affections of the heart itself, or of the parte 



PRACTICE OF PHYSIC. 37$ 

immediately connected with it, particularly the great ves- 
sels which pour blood into, or immediately receive it from, 
the cavities of the heart. Thus a dilatation or aneurism 
of the heart, a polypus in its cavities, abscesses or ulcera- 
tions in its substance, a close adherence of the pericardium 
to the surface of the heart, aneurisms of the great vessels 
near to the heart, polypus in these, and ossifications in 
these or in the valves of the heart, are one or other of them 
conditions which, upon dissection, have been discovered 
in those persons who had before labored under frequent 
syncope. 

1 186.] It is obvious, that these conditions are all of them, 
either such as may, upon occasion, disturb the free and 
regular influx into, or the free egress of the blood from, the 
cavities of the heart; or such as may otherwise disturb its 
regular action, by sometimes interrupting it, or sometimes 
exciting it to more violent and convulsive action. The lat- 
ter is what is named the Palpitation of the Heart, and it 
commonly occurs in the same persons who are liable to 
syncope. 

1 187.] It is this, as I judge, that leads us to perceive in 
what manner these organic affections of the heart and great 
vessels may occasion syncope : for it may be supposed, that 
the violent exertions made in palpitations may either give 
occasion to an alternate great relaxation, (1178.) or to a 
spasmodic contraction ; and in either way suspend the ac- 
tion of the heart, and occasion syncope. It seems to me 
probable, that it is a spasmodic contraction of the heart 
that occasions the intermission of the pulse so frequently ac- 
companying palpitation and syncope. 

1188.] Though it frequently happens that palpitation 
and syncope arise, as we have said, from the organic affec- 
tions above mentioned, it is proper to observe, that these 
diseases, even when in a violent degree, do not always de- 
pend on such causes acting directly on the heart, but are 
often dependent on some of those causes which we have 
mentioned above as acting primarily on the brain. 

1189.] I have thus endeavored to give the pathology of 
syncope ; and of the cure 1 can treat very shortly. 

The cases of syncope depending on the second set of 
causes, (1174.) and fully recited in 1185, I suppose to be 
generally incurable ; as our art, so far as I know, has not 
yet taught us to cure any one of those several causes of 
syncope (11S5.) 



37* PRACTICE OF PHYSIC. 

The cases of syncope depending on the first set of cau* 
ses, (1174.) and whose operation I have endeavored to ex- 
plain in 1 177. et seq. I hold to be generally curable, either 
by avoiding the several occasional causes there pointed out, 
or by correcting the predisponent causes (1184.) The lat- 
ter, I think, may generally be done by correcting the debi- 
lity or mobility of the system, by the means which I have 
already had occasion to point out in another place.* 



CHAPTER II. 
OF DYSPEPSIA, OR INDIGESTION. 

1190.] A WANT of appetite, a squeamishness, some- 
jLX. times a vomiting, sudden and transient dis- 
tentions of the stomach, eructations of various kinds, heart- 
burns, pains in the region of the stomach, and a bound 
belly, are symptoms which frequently concur in the same 
persons and therefore may be presumed to depend upon 
one and the same proximate cause. In both views, there- 
fore, they may be considered as forming one and the same 
disease, to which we have given the appellation of Dys- 
pepsia, set at the head of this chapter. 

1191.] But as this disease is also frequently a secondary 
and sympathic affection, so the symptoms above-mentioned 
are often joined with many others ; and this has given oc- 
casion to a very confused and undetermined description of 
it, under the general title of Nervous Diseases, or under 
that of Chronic Weakness. It is proper, however, to dis- 
tinguish them ; and I apprehend the symptoms enumerated 
above are those essential to the idiopathic affection I am 
now to treat of. 

1192.] It is indeed to be particular!}' observed, that 
these symptoms are often truly accompanied with a certain 
state of mind which may be considered as a part of the 
idiopathic affection : but I shall take no further notice of 
this symptom in the present chapter, as it will be fully and 
more properly considered in the next, under the title of 
Hypochondriasis. 

1 193.] That there is a distinct disease attended always 
with the greater part of the above symptoms, is rendered 
very probable by this, that all these several symptoms may 

* See article 217, fcc. 



PRACTICE OF PHYSIC. S7J 

arise from one and the same cause ; that is, from an imbe- 
cility, loss of tone, and weaker action in the muscular fi- 
bres of the stomach : and I conclude, therefore, that this 
imbecility may be considered as the proximate cause of 
the disease I am to treat of under the name of Dyspepsia. 
1194.] The imbecility of the stomach, and the conse- 
quent symptoms, (1190.) may, however, frequently de- 
pend upon some organic affection of the stomach itself, as 
tumor, ulcer, or schirrosity ; or upon some affection of 
other parts of the body communicated to the stomach, as 
in gout, amenorrhcea, and some others. In all these cases, 
however, the dyspeptic symptoms are to be considered as 
secondary or sympathic affections, to be cured only by 
curing the primary disease. Such secondary and sympathic 
cases cannot, indeed, be treated of here : but as I presume 
that the imbecility of the stomach may often take place 
without either any organic affection of this part, or any 
more primary affection in any other part of the body ; so 
I suppose and expect it will appear, from the consideration 
of the remote causes, that the dyspepsia may be often an 
idiopathic affection, and that it is therefore properly taken 
into the system of methodical Nosology, and becomes the 
subject of our consideration here. 

1195.] There can be little doubt, that in most cases, 
the weaker action of the muscular fibres of the stomach, is 
the most frequent and chief cause of the symptoms men- 
tioned in (1190.) but I dare not maintain it to be the only 
cause of idiopathic dyspepsia. There is, pretty certainly, 
a peculiar fluid in the stomach of animals, or at least a pe- 
culiar quality in the fluids, that Ave know to be there, up- 
on which the solution of the aliments taken into the stomach 
chiefly depends : and it is at the same time probable, that 
the peculiar quality of the dissolving or digesting fluids 
may be variously changed, or that their quantity may be, 
upon occasion, diminished. It is therefore sufficiently 
probable, that a change in the quality or quantity of these 
fluids may produce a considerable difference in the pheno- 
mena of digestion, and particularly may give occasion to 
many of the morbid appearances mentioned in 1 190. 

1196.] This seems to be very well founded, and points 
out another proximate causes of dyspepsia beside that we 
have already assigned: but, notwithstanding this, as the 
peculiar nature of the digestive fluid, the changes which it 
may undergo, or the causes by which it may be changed, 



S76 PRACTICE OF PHYSIC. 

are all matters so little known, that I cannot found any 
practical doctrine upon any supposition with respect to 
them; and us, at the same time, the imbecility of the sto- 
mach, either as causing the change in the digestive ilnid, 
or as being induced by that change;, seems always to be pre- 
sent, and to have a great share in occasioning the symp- 
toms of indigestion; so I shall still consider the imbecility 
of the stomach as the proximate and almost sole cause of 
dyspepsia. And I more readily admit of this manner of 
proceeding; as, in my opinion, the doctrine applies very 
fully and clearly to the explaining the whole of the. prac- 
tice which experience has established as the most success- 
ful in this disease. 

1197.] Considering this, then, as the proximate cause 
of dyspepsia, I proceed to mention the several remote 
causes of this disease; as they are such, as, on different 
occasions, seem to produce a loss ot tone in the muscular 
fibres of the stomach. They may, I think, be considered 
under two heads. The first is, of those which act directly 
and immediately upon the stomach itself: The second is, 
of those which act upon the whole body, or particular 
parts of it, but in consequence of which the stomach is 
chiefly or almost only affected. 

1198.] Of the first kind are, 

1. Certain sedative or narcotic substances taken into the 
stomach; such as tea, coffee, tobacco, ardent spirits, opi- 
um, bitters, aromatics, putrids, and acescents. 

2. The large and frequent drinking of warm water, or 
of warm watery liquids. 

3. Frequent surfeit, or immoderate repletion of the 
stomach. 

4. Frequent vomiting whether spontaneously arising, or 
excited by art. 

5. Very frequent spitting, or rejection of saliva. 
1199-] Those causes which act upon the whole body, 

or upon particular parts and functions of it, are, 

1. An indolent and sedentary life. 

2. Vexation of mind, and disorderly passions of any kind. 

3. Intense study, or close application to business too long 
continued. 

4. Excess in venery. 

5. Frequent intoxication ; which partly belongs to this 
head, partly to the former. 



PRACTICE OF PHYSIC. 377 

6. The being much exposed to moist and cold air when 
without exercise. 

1200.] Though the disease, as proceeding from the last 
set of causes, may be considered as a symptomatic affec- 
tion only ; yet as the affection of the stomach is generally 
the first, always the chief, and often the only effect which 
these causes produce or discover, I think the affection of 
the stomach may be considered as the disease to be attend- 
ed to in practice; and the more properly so, as in many 
cases the general debility is only to be cured by restoring 
the tone of the stomach, and by remedies first applied to 
this organ. 

1 201 .] For the cure of this disease, we form three sever- 
al indications; a preservative, a palliative, and a curative. 

The first is, to avoid or remove the remote causes just 
now enumerated. 

The second is, to remove those symptoms which especially 
contribute to aggravate and continue the disease. And, 

The third is, to restore the tone of the stomach ; that is, 
to correct or remove the proximate cause of the disease. 

1 202.] The propriety and necessity of the first indica- 
tion is sufficiently evident, as the continued application, or 
frequent repetition of those causes, must continue the dis- 
ease ; may defeat the use of the remedies : or, in spite of 
these, may occasion the recurrence of the disease. It is 
commonly the neglect of this indication which renders this 
disease so frequently obstinate. — How the indication is to 
be executed, will be sufficiently obvious from the consi- 
deration of the several causes: but it is proper for the prac- 
titioner to attend to this, that the execution is often ex- 
ceedingly difficult, because it is not easy to engage men to 
break in upon established habits, or to renounce the pur- 
suit of pleasure; and particularly, to persuade men that 
these practices are truly hurtful which they have often 
practised with seeming impunity. 

1203.] The symptoms of this disease which especially 
contribute to aggravate and continue it, and therefore re- 
quire to be more immediately corrected or removed, are, 
first, the crudities of the stomach already produced by the 
disease, and discovered bv a loss of appetite, by a sense of 
weight and uneasiness in the stomach, and particularly by 
the eructation of imperfectly digested matters. 

Another svmptom to be immediately corrected, is an 
unusual quantity, or a higher degree than usual, of acidity 

3c 



378 PRACTICE OF PHYSIC. 

present in the stomach, discovered by various disorders irf 
digestion, and by other effects to be mentioned afterwards. 

The third symptom aggravating the disease, and other- 
wise in itself urgent, is costiveness, and therefore constant- 
ly requiring to be relieved. 

1204.] The first of these symptoms is to be relieved by 
exciting vomiting; and the use of this remedy, therefore, 
usually and properly begins the cure of this disease. The 
vomiting may be excited by various means, more gentle 
or more violent. The former may answer the purpose of 
evacuating the contents of the stomach: but emetics, and 
vomiting, may also excite the ordinary action of the sto- 
mach; and both, by variously agitating the system, and 
particularly by determining to the surface of the body, 
may contribute to remove the causes of the disease. But 
these latter effects can only be obtained by the use of eme- 
tics of the more powerful kind, such as the antimonial eme- 
tics especially are.* 

1205.] The second symptom to be palliated, is an excess 
of acidity, either in quantity or quality, in the contents of 
the stomach. In man there is a quantity of acescent ali- 
ment almost commonly taken in, and, as 1 think, always 
undergoes an acetous fermentation in the stomach ; and it 
is therefore that, in the human stomach, and in the sto- 
machs of all animals using vegetable food, there is always 
found an acid present. This acid, however, is generally 
innocent, and occasions no disorder, unless either the 
quantity of it is large, or the acidity proceeds to a higher 
degree' than usual. But, in either of these cases, the acid 
occasions various disorders, as flatulency, eructation, heart- 
burn, gnawing pains of the stomach, irregular appetites 
and cravings, looseness, griping, emaciation, and debility. 
To obviate or remove these effects aggravating and conti- 
nuing the disease, it is not only necessary to correct the 
acid present in the stomach ; but, especially as this acid 
proves a ferment determining and increasing the acescency 
of the aliments afterwards taken in, it is proper also, as 
soon as possible, to correct the disposition to excessive 
acidity. 

1206.] The acidity present in the stomach may be cor- 
rected by the use of alkaline salts, or absorbent earths ;f 

* The formula? and doses of antimonial emetics have been described in a note on article 185. 

+ No part of the practice of physic requires more caution than the adminisienng alkjline salts 
and absorbent earths. The alkaline salts, by their caustic quality, corrode the ttomach, and 
blunt its action, when taken in too large quantities ; and especially if, from a mistaken diacno- 
eis, do acid is in the stomach. Lime water is certainly preferable to the alkaline salts ; iti dose 



PRACTICE OF PHYSIC. 319. 

m by such substances, containing these, as can be decom- 
posed by the acid of the stomach. Of the alkalines, the 
caustic is more effectual than the mild ; and this accounts for 
the effects of lime-water. By employing absorbents, we 
avoid the excess of alkali, which might sometimes take 
place. The absorbents are different, as they form a neu- 
tral more or less laxative ; and hence the difference between 
magnesia alba and other absorbents. It is to be observed, 
that alkalines, and absorbents may be employed to excess ; 
as, when employed in large quantity, they may deprive 
the animal fluids of the acid necessary to their proper com- 
position. 

1207.] The disposition to acidity may be obviated by 
avoiding acescent aliments, and using animal food little ca- 
pable of acescency. This, however, cannot be long con- 
tinued without corrupting the state of our blood ; and as 
vegetable food cannot be entirely avoided, the. excess of 
their acescency may in some measure be avoided, by choos- 
ing vegetable food the least disposed to a vinous fermenta- 
tion, such as leavened bread and well fermented liquors, 
and, instead of fresh native acids, employing vinegar. 

1208.1 The acid arising from acescent matters in a sound 
state of the stomach, does not proceed to any high degree, 
or is again soon involved and made to disappear: but this 
does not always happen ; and a more copious acidity, or 
a higher degree of it, may be produced, either from a 
change in the digestive fluids, become less fit to moderate 
fermentation and to cover acidity, or from their not being 
supplied in due quantity. How the former may be occa- 
sioned, we do not well understand ; but we can readily 
perceive that the latter, perhaps the former also, may pro- 
ceed from a weaker action of the muscular fibres of the sto- 

snay vary from two to four ounces twice a-day, according to the urgency of the case. The ab- 
sorbent earths, as chalk , crabs eyes, .Vc. if they do not meet with an acid, arc apt to concrete into 
a hard indi ifuble mass, by the mucus of the stomach. Magnesia is duubtless in many cases, 
preferabl,- to .1 calcareous earth : when, on account of its purgative quality, we cannot continue 
its use, chalk is preferable to the testaceous powders, because it is free from that glutinous sub- 
stance with which testaceous powders abound, and which the more readil) disposes them to 
concrete in the stomach. The dose of magnesia is from one scruple to one drachm. tw ' c c or 
thrice a dav ; and its purgative quality may, in many cases, be prevented, by adding to each dose 
•f it ten or fifteen crams of rhubarb, ami live or six drops of oil of aniiC-seed The Decoctara 
inburgh Pharmacopoeia is a good form lor die exhibition of chalk n"t 
chalk may be given with rhubarb and oil of anise-seeds, like magnesia. The Trochisc) e creu 
fa a convenient form lor giving the chalk, had die crabs eyes been omitted. The following anta- 
cid troches are both effectual and pleasant : 

R. Magnes. alb. Bvi. 
Sacch. alb. §iii. 
Nuc. mosch. 9ii. 
M. f. trochisci cum mucilagin. gum. tragacanth. q. s. 



380 PRACTICE OF PHYSIC. 

macb. In certain cases, sedative passions, immediately 
after they arise, occasion the appearance of acidity In the 
stomach which did not appear before ; and the use of stimu- 
lants often corrects or obviates an acidity that would other- 
wise have appeared. From these considerations, we con- 
clude, that the production and subsistence of acidity in the 
stomach, is to be especially prevented by restoring and ex- 
citing the proper action of it, by the several means to be 
mentioned hereafter. 

1209.] But it is also to be further observed, that though 
there are certain powers in the stomach for preventing a too 
copious acidity, or a high degree of it, they are not bow- 
ever always sufficient for preventing acescency, or for co- 
vering the acidity produced ; and therefore, as long as ve- 
getable substances remain in the stomach, their acescency 
may go on and increase. From hence we perceive, that a 
special cause of the excess of acidity may be, the too long 
retention of acescent matters in the stomach ; whether this 
may be from these matters being of more difficult solution, 
or from the weakness of the stomach more slowly discharg- 
ing its contents into the duodenum, or from some impedi- 
ment to the free evacuation of the stomach by the pylorus. 
The latter of these causes we are well acquainted with, in 
the case of a scirrhous pylorus, producing commonly the 
highest degree of acidity. In all the instances of this scir- 
rhosity I have met with, I have found it incurable : but the 
first of these causes is to be obviated by avoiding such ali- 
ments as are of difficult solution ; and the second is to be 
mended by the several remedies for exciting the action of 
the stomach, to be mentioned afterwards. 

1210.] The third symptom commonly accompanying 
dyspepsia, which requires to be immediately removed, is 
costivencss. There is so much connection between the se- 
veral portions of the alimentary canal with respect to the 
peristaltic motion, that, if accelerated or retarded in any 
one part, the other parts of it are commonly affected in the 
same manner. Thus, as the brisker action of the stomach 
must accelerate the action of the intestines, so the slower 
action of the intestines must in some measure retard that of 
the stomach. It is therefore of consequence to the proper 
action of the stomach, that the peristaltic motion of the in- 
testines determining their contents downwards, be regularly 
continued; and that all costiveness, or interruption of that 
determination, be avoided. This may be done by the va- 



PRACTICE OF PHYSIC. 3d I 

rious means of exciting the action of the intestines : bat it 
is to be observed here, that as every considerable evacua- 
tion of the intestines weakens their action, and is ready 
therefore to induce costivenesss when the evacuation is over ; 
to tiiose purgatives which produce a large evacuation, are 
unlit for correcting the habit of costiveness. This, there- 
fore, should be attempted by medicines which do no more 
than solicit the intestines to a more ready discharge of their 
present contents, without either hurrying their action, or 
increasing the excretions made into their cavity j either of 
which effects might produce a purging. There are, I think, 
certain medicines peculiarly proper on this occasion, as they 
seem to stimulate especially the great guts, and to act little 
on the higher parts of the intestinal canal.* 

121 1.] We have thus mentioned the several means of ex- 
ecuting our second indication ; and I proceed to the third, 
which is, as we have said, the proper curative ; and it is 
to restore the tone of the stomach, the loss of which we 
consider as the proximate cause of the disease, or at least 
as the chief part of it. The means of satisfying this indi- 
cation we refer to two heads. One is, of those means which 
operate directly and chiefly on the stomach itself; and the 
other is, of those means which, operating upon the whole 
system, have their tonic effects thereby communicated to 
the stomach. 

1212.] The medicines which operate directly on the sto- 
mach are either stimulants or tonics. 
The stimulants are saline or aromatic. 
The saline are acids or neutrals. 

Acids of all kinds seem to have the power of stimulating 
the stomach, and therefore often increase appetite : but 
the native acids, as liable to fermentation, may otherwise 
do harm, and are therefore of ambiguous use. The acids, 
therefore, chiefly and successfully employed are the vitri- 
olic, f muriatic,! and the distilled acid of vegetables, as it 
is found in tar-water, which are all of them antizymics § 

The neutral salts answering this intention are especially 
those which have the muriatic acid in their composition, 

•Ten or fifteen miir of Pil. Ruf. answer this purpose sufficiently w*»v » <* t0 be Kitted 
I the Author did npt mention those certain mtdic'ma to which he alludes. .,. . 

4 1 he dose of the vitriolic acid ought not to exceed ten drops, and u should be well <.i,utea 

t The Tmcturs Martis of the Edinburgh College powerfully stimulates the stomach, and jk* 
at the same time as a tonic ; it, dove is from ten to twenty drops thrice a-dav, in a >wncie«i 
quantity of an hide, and it ts a very agteeaUe medic.ne. 

{ I. e. 'Resist termeni .tion. 



382 PRACTICE OF PHYSIC. 

though it is presumed that neutrals of all kinds have more 
or less of the same virtue.* 

1213.] The aromatics, and perhaps some other acrids, 
certainly stimulate the stomach, as they obviate the aces- 
cency and flatulency of vegetable food : but their stimulus 
is transitory ; and if frequently repeated, and taken in large 
quantities, they may hurt the tone of the stomach. f 

1214.] The tonics employed to strengthen the stomach 
are bitters, bitters and astringents combined, and chaly- 
beates. 

Bitters are undoubtedly tonic medicines, both with res- 
pect to the stomach and the whole system : but their long- 
continued use has been found to destroy the tone of the 
stomach and of the whole system ; and, whether this is from 
the mere repetition of their tonic operation, or from some 
narcotic power joined with the tonic in them, I am uncertain. 

1215.] Bitters and astringents combined are probably 
more effectual tonics than either of them taken singly ; and 
we suppose such a combination to take place in the Peruvian 
bark ; which therefore proves a powerful tonic, both with 
respect to the stomach and to the whole system. But I have 
some ground to suspect that the long continued use of this 
bark may, like bitters, destroy, both the tone of the sto- 
mach and of the whole system. % 

1216.] Chalybeates may be employed as tonics in various 
forms, § and in considerable quantities, with safety. They 
have been often employed in the form of mineral waters, 
and seemingly with success : but, whether this is owing to 
the chalybeate in the composition of these waters, or to 
some other circumstances attending their use, I dare not 
positively determine ; but the latter opinion seems to me 
the more probable. 

12H.] The remedies which strengthen the stomach, by 
being applied to the whole body, are, exercise, and the ap- 
plication of cold. 

* The Sal digestivus, i. e. the muriatic acid saturated with vegetable fixed alkali, was thought 
to be preferable to common salt in promoting digestion. Hence its old name of Sal digestivus. 
Its superiority over common salt is however doubtful. 

+ This caution against the too free use of aromatics ought to be peculiarly attended to by the 
young practitioner. The speedy relief which they produce tempts the patient to have frequent 
recourse to them, which, as the author justly observes, may materially hurt the tone of the sto- 
mach, and consequently increase the disease which they were intended to remove. 

t Forms of these tonics may be seen in the preceding notes on articles 'J8I. 982. 992. 

i 6ee the notes on articles 981. 982. 992. In these cases the Tinctura Msrtis mentioned in the 
note on article 1212. is as proper a form of chalybeates as any we can use. Its dose is from ten 
to twenty drops in any proper vehicle. A glass of cold spring water, acidulated with a few drops 
of this tincture, is agreeable and refreshing, and may be used as the patient's common drink : 
its agreeableness may be considerably increased by adding to each half-pint glass a table-spoon- 
ful of simple cinnamon water. 



PRACTICE OF PHYSIC. .383 

As exercise strengthens the whole body, it must also 
Btrengthen the stomach ; but it does this also in a particular 
manner, by promoting perspiration, and exciting the action 
of the vessels on the surface of the body, which have a 
particular consent with the muscular fibres of the stomach. 
This particularly explains why the exercises of gestation, 
though not the most powerful in strengthening the whole 
system, are, however, very powerful in strengthening the 
stomach j of which we have a remarkable proof in the ef- 
fects of sailing. In strengthening the general system, as fa- 
tigue must be avoided, so bodily exercise is of ambiguous 
use ; and perhaps it is thereby that riding on horseback has 
been so often found to be one of the most powerful means of 
strengthening the stomach, and thereby of curing dyspepsia. 
12T8.] The other general remedy of dyspepsia is the ap- 
plication of cold ; which may be in two ways ; that is, ei- 
ther by the application of cold air, or of cold water. It is 
probable, that, in the atmosphere constantly surrounding 
our bodies, a certain degree of cold, considerably less than 
the temperature of our bodies themselves, is necessary to 
the health of the human body. Such a degree of cold seems 
to strengthen the vessels on the surface of the body, and 
therefore the muscular fibres of the stomach. But, further, 
it is well known, that if the body is in exercise sufficient to 
support such a determination to the surface, as to prevent 
the cold from producing an entire constriction of the pores ; 
a certain degree of cold in the atmosphere, with such ex- 
ercise, will render the perspiration more considerable. From 
the sharp appetite that in such circumstances is commonly 
produced, we can have no doubt, that by the application 
of such cold, the tone of the stomach is considerably strength- 
ened. Cold air, therefore, applied with exercise, is a most 
powerful tonic with respect to the stomach ; and this ex- 
plains why, for that purpose, no exercises within doors, or 
in close carriages, are so useful as those in the open air. 

121!). J From the same reasoning, we can perceive, that 
the application of cold water, or cold bathing, while it is a 
tonic with respect to tin- system in general, and especially 
as exciting the action of the extreme vessels, must in both 
respects be a powerful means of strengthening the tone of 
the stomach. , 

1220.] These are the remedies to be employed towards a 
radical cure of idiopathic dyspepsia ; and it might be, per- 
haps, expected here, that I si-.ould treat also of the various 



384 PRACTICE OF PHYSIC. 

cases of the sympathic disease. But it will be obvious that 
this cannot be properly done without treating of all the dis- 
eases of which dyspepsia is a symptom, which cannot be 
proper in this place. It has been partly done already, and 
will be further treated of in the course of this work. In 
the mean time, it may be proper to observe, that there is 
not so much occasion for distinguishing between the idiopa- 
thic and sympathic dyspepsia, as there is in many other 
cases of idiopathic and sympathic diseases. For,' as the 
sympathic cases of dyspepsia are owing to a Joss of tone in 
some other part of the system, which is from thence com- 
municated to the stomach : so the tone of the stomach re- 
stored, may be communicated to the part primarily af- 
fected ; and therefore the remedies of the idiopathic may be 
often usefully employed, and are often the remedies chiefly 
employed in sympathic dyspepsia. 

122L] Another part of our business here might be to 
say, how some other of the urgent symptoms, besides those 
above-mentioned, are to be palliated. On this subject, I 
think it is enough to say, that the symptoms chiefly requir- 
ing to be immediately relieved, are flatulency, heartburn, 
other kinds of pain in the region of the stomach, and 
vomiting. 

The dyspeptic are ready to suppose that the whole of 
their disease consists in a flatulency, hi this it will be ob- 
vious that they are mistaken; but, although the flatulency 
is not to be entirely cured, but by mending the imbecility 
of the stomach by the means above-mentioned ; yet the fla- 
tulent distention of the stomach may be relieved by carmi- 
natives, as they are called, or medicines that produce a 
discharge of wind from the stomach : such are the various 
antispasmodics, of which the most effectual is the vitriolic 
sether. 

The heartburn may be relieved by absorbents,* antispas- 
modics, f or demulcents.:]; 

The other pains of the stomach may be sometimes re- 
lieved by carminatives, § but most certainly by opiates. 

Vomiting is to be cured most effectually by opiates 
thrown by injection into the anus. 

• The absorbents have been described above, see not? on article 1306. 

+ It mav be doubtful whether antispasmodics are effectual in removing heartburn. Opium 
Undoubledly often gives relief in doses of twenty or thirty drops of laudanum 

t F.uract of liquorice is as goo'i a demulcent in these cases as any in the list of the Materia 
Medica. Suckin:; a little piece of it, and drinking a cup or two of weak lintseed tea after it, 
seldom fail of giving relief. 

i Carminatives suitable in these cases are the essential oils of the seeds of some aromatic um- 
biliferous planu, as Ol. Anisi, the dose of which is fifteen or twenty drops on a piece of sugar, 



PRACTICE OF PHYSIC. 385 



CHAPTER III. 

OF HYPOCHONDRIASIS, OR THE HYPOCHON- 
DRIAC AFFECTION, COMMONLY CALLED 
VAPORS, OR LOW SPIRITS. 

1222.] TN certain persons there is a state of mind dis- 
jl tinguished by a concurrence of the following 
circumstances : A languor, listlessness, or want of resolu- 
tion and activity with respect to all undertakings ; a dispo- 
sition to seriousness, sadness and timidity ; as to all future 
events, an apprehension of the worst or most unhappy state 
of them ; and therefore, often upon slight grounds, an ap- 
prehension of great evil. Such persons are particularly at- 
tentive to the state of their own health, to even the smallest 
change of feeling in their bodies ; and from any unusual 
feeling, perhaps of the slightest kind, they apprehend great 
danger, and even death itself. In respect to all these feel- 
ings and apprehensions, there is commonly the most obsti- 
nate belief and persuasion. 

1223.] This state of mind is the Hypochondriasis of me- 
dical writers. See Linnaei Genera Morborum, Gen. 76. 
et Segari Systema Symtomaticum, Class XIII. Gen. 5. 
The same state of mind is what has been commonly called 
Vapors and Loxo Spirits. Though the term Vapors may 
be founded on a false theory, and therefore improper, I beg 
leave, for a purpose that will immediately appear, to em- 
ploy it for a little here. 

1224.] Vapors, then, or the state of mind described 
above, is, like every other state of mind, connected with a 
certain state of the body, which must be inquired into in 
order to its being treated as a disease by the art of physic. 

1225.] This state of the body, however, is not very easily 
ascertained : for we can perceive, that on different occasions 
it is very different ; vapors being combined sometimes with 
dyspepsia, sometimes with hysteria, and sometimes with 
melancholia, which are diseases seemingly depending on 
very different states of the body. 

though common practice seldom goes half that length. The Oleum Carvi is another excellent 
carminative, but it is very hot, and its dose must never exceed five drops; two drops are a mo- 
derate dose. Tin- oleum Mi-nthae is anothergood carminative; its dose is two or three drops 
■■ of sugar. Two grains of the Extract of Opium, or forty drops of the Laudanum, are 
usually given in half a cuptul of lintseed tea. The dose may be increased to 100 drops of lau- 
danum, in the same quantity of vehicle, especially if the pain of the tlomacu be accompanied 
will) vomitings. 

9* 



386 PRACTICE OF PHYSIC. 

1226.] The combination of vapors with dyspepsia is very 
frequent, and in seemingly very different circumstances. 
It is, especially, these different circumstances that I would 
wish to ascertain ; and I remark, that they are manifestly 
of two different kinds. First, as the disease occurs in young 
persons of both sexes, in persons of a sanguine tempera- 
ment, and of a lax and flaccid habit. Secondly, as it oc- 
curs in elderly persons of both sexes, of a melancholic tem- 
perament, and of a firm and rigid habit. 

1227.] These two different cases of the combination of 
vapors and dyspepsia, I consider as two distinct diseases, 
to be distinguished chiefly by the temperament prevailing 
in the persons affected. 

As the dyspepsia of sanguine temperaments is often with- 
out vapors ; and as the vapors when joined with dyspepsia 
in such temperaments, may be considered as, perhaps, al- 
ways a symptom of the affection of the stomach ; so to this 
combination of dyspepsia and vapors, I would still apply 
the appellation of Dyspepsia, and consider it as strictly the 
disease treated of in the preceding chapter. 

But the combination of dvspepsia and vapors in melan- 
cholic temperaments, as the vapors or the turn of mind pe- 
culiar to the temperament, nearly that described above ia 
1222, are essential circumstances of the disease ; and as 
this turn of mind is often with few, or only slight symptoms 
of dyspepsia ; and, even though the latter be attending, as 
they seem to be rather the effects of the general tempera- 
ment, than of any primary or topical affection of the sto- 
mach ; I consider this combination as a very different dis- 
ease from the former, and would apply to it strictly the ap- 
pellation of Hypochondriasis. 

1228.] Havingthus pointed outadistinction between Dys- 
pepsia and Hypochondriasis, I shall now, using these terms 
in the strict sense above mentioned, make some observations 
which may, I think, illustrate the subject, and more clearly 
and fully establish the distinction proposed. 

1229.] The dyspepsia often appears early in life, and is 
frequently much mended as life advances : but the hypo- 
chondriasis seldom appears early in life, and more usually 
in more advanced years only; and more certainly still, 
when it has once taken place, it goes on increasing as life 
advances to old age. 

This seems to be particularly well illustrated, by our ob- 
serving the changes in the state of the mind which usually 



PRACTICE OF PHYSIC. 387 

take place in the course of life. In youth, the mind is 
chearful, active, rash, and moveable : but, as life advan. 
ces the mind by degrees becomes more serious, slow, cau- 
tious, and steady ; till at length, in old age, the gloomy, 
timid, distrustful, and obstinate state of melancholic tem- 
peraments, is more exquisitely formed. In producing these 
changes, it is true, that moral causes have a share ; but it is 
at the same time obvious, that the temperament of the body 
determines the operation of these moral causes, sooner or 
later, and in a greater or lesser degree, to have their ef- 
fects. The sanguine temperament retains longer the charac- 
ter of youth, while the melancholic temperament brings on 
more early the manners of old age. 

1230.] Upon the whole, it appears, that the state of the 
mind which attends, and especially distinguishes hypochon- 
driasis, is the effect of that same rigidity of the solids, tor- 
por of the nervous power, and peculiar balance between 
the arterial and venous systems which occur in advanced 
life, and which at all times take place more or less in melan- 
cholic temperaments. If therefore there be also somewhat 
of a like state of mind attending the dyspepsia which occurs 
early in life in sanguine temperaments and lax habits, it 
must depend upon a different state of the body, and pro- 
bably upon a weak and moveable state of the nervous power. 
1231.] Agreeable to all this in dyspepsia, there is more 
of spasmodic affection, and the affection of the mind ( 1 222.) 
is often absent, and, when present, is perhaps always of a 
slighter kind ; while in hypochondriasis the affection of the 
mind is more constant, and the symptom's of dyspepsia, or 
the affections of the stomach, are often absent, or, when 
present, are in a slighter degree. 

I believe the affection of the mind is commonly different 
in the two diseases. In dyspepsia, it is often languor and 
timidity only, easily dispelled ; while, in hypochondriasis, 
it is generally the gloomy and ri vetted apprehension of evil. 
The two diseases are also distinguished by some other 
circumstances. Dyspepsia, as 1 have said, is often a symp- 
tomatic affection ; while hypochondriasis is, perhaps, al- 
ways a primary and idiopathic disease. 

As debility may be induced by many different causes, 
dyspepsia is a frequent disense ; while hypochondriasis, de- 
pending upon a peculiar temperament, is more rare. 

12I>2.] Having thus endeavored to distinguish the two 
diseases, I suppose the peculiar nature and proximate cause 



388 PRACTICE OF PHYSIC. 

of hypochondriasis will be understood ; and I proceed, 
therefore, to treat of its cure. 

So far as the affections of the body, and particularly of 
the stomach, are the same here as in the case* of dyspepsia, 
the method of cure might be supposed to be also the same; 
and accordingly the practice has been carried on Avith lit- 
tle distinction: but I am persuaded that a distinction is of- 
ten necessary. 

1233.] There may be a foundation here for the same 
preservative indication as first laid down in the cure of 
dyspepsia; (1202.) but I cannot treat this subject so clearly 
or fully as I could wish, because I have not yet had so 
much opportunity of observation as I think necessary to as- 
certain the remote causes; and I can hardly make use of 
theobservations of others, who have seldom or never distin- 
guished between the two diseases. What, indeed has been 
said with respect to the remote causes of melancholia, will 
often apply to the hypochondriasis, which I now treat of; 
but the subject of the former has been so much involved 
in a doubtful theory, that I rind it difficult to select the 
facts that might properly and strictly apply to the latter. 
I delay this subject, therefore, till another occasion ; but 
in the mean time trust, that what I have said regarding the 
nature of the disease, and some remarks I shall have occa- 
sion to offer in considering the method of cure, may in 
some measure supply my deficiency on this subject of the 
remote causes. 

1234.] The second indication laid down in the cure of 
dyspepsia (1201.) has properly a place here; but it is still 
to be executed with some distinction. 

1235.] An anorexia, and accumulation of crudities in 
the stomach, does not commonly occur in hypochondriasis 
as in dyspepsia ; and therefore vomiting (1204.) is not so 
often necessary in the former as in the latter. 

1236.] The symptom of excess of acidity, from the slow 
evacuation of the stomach in melancholic temperaments, 
often arises to a very high degree in the hy pochond riasis ; and 
therefore, for the same reason as in 1205, it is to be obviat- 
ed and corrected with the utmost care. It is upon this ac- 
count that the several antacids, and the other means of ob- 
viating acidity, are to be employed in hypochondriasis, and 
with the same attentions and considerations as in 1206. and 
following ; with this reflection, however, that the exciting 



PRACTICE OF PHYSIC. 389 

the action of the stomach there mentioned, is to be a little 
differently understood, as shall be hereafter explained. 

1237] As costiveness, and that commonly to a conside- 
rable degree, is a very constant attendant of hypochondria- 
sis, so it is equally hurtful as in dyspepsia. It may be reme- 
died by the same means in the former as in the latter, and 
they are to be employed with the same restrictions as in 
1210. 

1238.] It is especially with respect to the third indica- 
tion laid down in the cure of dyspepsia (1201.) that there 
is a difference of practice to be observed in the cure of hy- 
pochondriasis ; and that often one directly opposite to that 
in the case of dyspepsia, is to be followed. 

1239.] In dyspepsia, the chief remedies are the tonic 
medicines, which to me seem neither necessary nor safe in 
hypochondriasis ; for in this there is not a loss of tone, but 
a want of activity that is to be remedied. 

Chalybeate mineral waters have commonly been em- 
ployed in hypochondriasis, and seemingly with success. 
But this is probably to be imputed to the amusement and 
exercise usually accompanying the use of these waters, 
rather than to the tonic power of the small quantity of iron 
which they contain. Perhaps the elementary water, by 
favoring the excretions, may have a share in relieving the 
disease. 

1240.] Cold bathing is often highly useful to the dys- 
peptic, and, as a general stimulant, may sometimes seem 
useful to the hypochondriac ; but it is not commonly so 
to the latter ; while, on the other hand, warm bathing, 
hurtful to the dyspeptic, is often extremely useful to the 
hypochondriac. 

1241.] Another instance of a contrary practice neces- 
sary in the two diseases, and illustrating their respective 
natures, is, that the drinking tea and coffee is always hurt- 
ful to the dyspeptic, but is commonly extremely useful to 
the hypochondriac. 

1242.] Exercise, as it strengthens the system, and there- 
by the stomach, and more especially, as by increasing the 
perspiration, it excites the action of the stomach, it proves 
one of the most useful remedies in dyspepsia ; and further, 
as, by increasing the perspiration, it excites the activity of 
the stomach, it likewise proves an useful remedy in the hy- 
pochondriasis. However, in the latter case, as I shall ex- 



390 PRACTICE OF PHYSIC. 

plain presently, it is still a more useful remedy by its ope- 
ration upon the mind than by that upon the body. 

1243.] It is now proper that we proceed to consider the 
most important article of our practice, in this disease, and 
which is, to consider the treatment of the mind ; an affec- 
tion of which sometimes attends dyspepsia, but is always 
the chief circumstance in hypochondriasis. What I am to 
suggest here, will apply to both diseases ; but it is the hy- 
pochondriasis that I am to keep most constantly in view. 

1244.] The management of the mind in hypochondriacs, 
is often nice and difficult. The firm persuasion that gene- 
rally prevails in such patients, does not allow their feelings 
to be treated as imaginary, nor their apprehension of dan- 
ger to be considered as groundless, though the physician 
may be persuaded that it is the case in both respects. Such 
patients, therefore, are not to be treated either by raillery, 
or by reasoning. 

It is said to be the manner of hypochondriacs to change 
often their physician ; and indeed they often do it consist- 
ently ; for a physician who docs not admit the reality of the 
disease, cannot be supposed to take much pains to cure it, 
or to avert the danger of which he entertains no appre- 
hension. 

If in any case the pious fraud of a placebo be allowable, 
it seems to be in treating hypochondriacs ; who, anxious 
for relief, are fond of medicines, and, though often disap- 
pointed, Avill still taste every new drug that caw be propos- 
ed to them. 

1245.] As it is the nature of man to indulge every pre- 
sent emotion, so the hypochondriac cherishes his fears ; and, 
attentive to every feeling, finds in trifles light as air, a 
strong confirmation of his apprehensions. His cure, there- 
fore, depends especially upon the interruption of his atten- 
tion, or upon its being diverted toother objects than his 
own feelings. 

1243.] Whatever aversion to application of any kind may 
appear in hypochondriacs, there is nothing more pernicious 
69 them than absolute idleness, or a vacancy from all earnest 
pursuit. It is owing to wealth admitting of indolence, and 
leading to the pursuit of transitory and unsatisfying amuse- 
ments, or to that of exhausting pleasures only, that the 
present timei exhibit to us so many instances of hypochon- 
driacism. 

The occupations of business suitable to their circum- 



PRACTICE OF PHYSIC. 391 

stances and situation in life, if neither attended with emo- 
tion, anxiety, nor fatigue, are always to be admitted, and 
persisted in by hypochondriacs. But occupations upon 
which a man's fortune depends, and which are always, there- 
fore, objects of anxiety to melancholic men ; and more 
particularly where such occupations are exposed to accident- 
al interruptions, disappointments, and failures, it is from 
these that the hypochondriac is certainly to be withdrawn. 

1247.] The hypochondriac who is not necessarily, by 
circumstance or habits, engaged in business, is to be drawn 
from his attention to his own feelings by some amusement. 

The various kinds of sport and hunting, as pursued with 
some ardor, and attended with exercise, if not too violent, 
are amongst the most useful. 

All those amusements which are in the open air, joined 
with moderate exercise, and requiring some dexterity, are 
generally of use. 

Withindoors, company which engages attention, which 
is willingly yielded to, and is at the same time of a chear- 
ful kind, will be always found of great service. 

Play, in which some skill is required, and where the stake 
is not an object of much anxiety, if not too long protract- 
ed, may often be admitted. 

In dyspeptics, however, gaming, liable to sudden and 
considerable emotions, is dangerous ; and the long continu- 
ance of it, with night watching, is violently debilitating. 
But in melancholies, who commonly excel in skill, and are 
less susceptible of violent emotions, it is more admissible, 
and is often the only amusement that can engage them. 

Music, to a nice ear, is a hazardous amusement, as long 
attention to it is very fatiguing. 

1248.] It frequently happens, that amusements of every 
kind are rejected by hypochondriacs ; and in that case, me- 
chanical means of interrupting thought are the remedies to 
be sought for. Such is to be found in brisk exercise, which 
requires some attention in the conduct of it. 

Walking is seldom of this kind ; though, as gratifying 
to the restlessness of hypochondriacs, it has sometimes been 
found useful. 

The required interruption of thought is best obtained by 
riding on horseback, or in driving a carriage of any kind. 

The exercise of sailing, except it be m an open boat, 
ing some attention, does very little service. 
ercite in an easy carriage, in the direction of which 



392 PRACTICE OF PHYSIC. 

the traveller takes no part, unless it be upon rough roads, 
or driven pretty quickly, and with long continuance, is of 
little advantage. 

1249.] Whatever exercise maybe employed, it will be 
most effectual when employed in the pursuit of a journey ; 
first, because it withdraws a person from many objects of 
uneasiness and care which might present themselves at home; 
secondly, as it engages in more constant exercise, and in a 
greater degree of it than is commonly taken in airings about 
home ; and lastly, as it is constantly presenting new objects 
which call forth a person's attention. 

1 250.] In our system of Nosology we have, next to Hy- 
pochondriasis, placed the Chlorosis, because I once thought 
it might be considered as a genus, comprehending, besides 
the Chlorosis of Amenorrhcea, some species of Cachexy : 
but, as I cannot find this to be well founded, and cannot 
distinctly point out any such disease, I now omit consi- 
dering Chlorosis as a genushere ; and, as a symptom of Ame- 
norrhcea, I have endeavored before to explain it under that 
title. 



BOOK III. 

OF SPASMODIC AFFFXTIONS WITHOUT 
FEVER. 

1251 .] n ' TNDER this title I am to comprehend all the 
i^J diseases which consist in motu abnormi ; 
that is, in a preternatural state of the contraction and mo- 
tion of the muscular or moving fibres in any part of the 
body. 

1252.] It will hence appear, why, under this title, I 
have comprehended many more diseases than Sauvages and 
Sagar have comprehended under the title of Spasmi, or 
than Linnaeus has done under the title of Motorii. But I 
expect it will be obvious, that upon this occasion, it would 
not be proper to confine our view to the affections of vo- 
luntary motion only ; and if those Nosologists have intro- 
duced into the class of Spasmi, Palpitatio and Hysteria, 
it will be with equal propriety that Asthma, Colica, and 
manv other diseases, are admitted. 



PRACTICE OF PHYSIC. 393 

1253.] It has been hitherto the method of our Nosolo- 
gists to divide the Spasmi into the two orders of Tonici and 
Cionici, Spastici, and Agitatorii ; or, as many at present 
use the terms, into Spasms strictly so called, and convul- 
sions. I find, however, that many, and indeed most of the 
diseases to be considered under our title of Spasmodic af- 
fections, in respect to Tonic or Clonic contractions, are of 
a mixed kind : and, therefore, I cannot follow the usual 
general division ; but have attempted another, by arrang- 
ing the several Spasmodic diseases according as they affect 
the several functions, Animal, Vital, or Natural. 



SECTION I. 

Of the Spasmodic Affections of the Animal Functions. 

] 254.] AGREEABLE to the language of the ancients, 
the whole of the diseases to be treated of in this section 
might be termed Spasmi ; and many of the moderns con- 
tinue to apply the term in the same manner : but I think it 
convenient to distinguish the terms of Spasm and Convul- 
sion, by applying the former, strictly to what has been cal- 
led the Tonic i and the latter, to what has been called the 
Clonic spasm. There is certainly a foundation for the use 
of those different terms, as there is a remarkable difference 
in the state of the contraction of moving fibres upon differ- 
ent occasions. This I have indeed pointed out before in 
my treatise of Physiology, but must also repeat it here. 

1255.] In the exercise of the several functions of the 
animal economy, the contractions of the moving fibres are 
excited by the will, or by certain other causes specially 
appointed by nature for exciting those contractions; and 
these other causes I name the natural causes. In a state of 
health, the moving fibres are contracted by the power of 
the will and by the natural causes only. At the same time, 
the contractions produced are, in force and velocity, regu- 
lated by the will, or by the circumstances of the natural 
causes ; and the contractions, whether produced by the 
one or the other, are always soon succeeded by a state of 
relaxation, and arc not repeated but when the power of 
tin- will or of the natural cause's is again applied. 

1 256.] Such are the conditions of the action of the mov- 
ing fibres in a state of health : but in a morbid state the 

9s 



394 PRACTICE OF PHYSIC. 

contractions of the muscles and moving fibres ordinarily 
depending upon the will are excited without the concur- 
rence of the will, or contrary to what the will intends; and 
in the other functions they are excited by the action of un- 
usual and unnatural causes. In both cases, the contrac- 
tions produced may be in two different states. The one is, 
when the contractions are to a more violent degree than is 
usual in health, and are neither succeeded by a spontane- 
ous relaxation, nor even readily yield to an extension either 
from the action of antagonist muscles, or from other extend- 
ing powers applied. This state of contractions is what has 
been called a tonic spasm, and is what I shall name simply 
and strictly a spasm. The other morbid state of contrac- 
tion is, when they are succeeded by a relaxation, but are 
immediately again repeated without the concurrence of 
the will or of the repetition of natural causes, and are at 
the same time commonly, with respect to velocity and 
force, more violent than in a healthy state. This state of 
morbid contraction is what has been named a clonic spasm, 
and what I shall name simply and strictly a convulsion. 

In this section I shall follow nearly the usual division of 
the spasmodic diseases into those consisting in Spasm, and 
those consisting in Convulsion ; but it may not perhaps be 
in my power to follow such division exactly. 



CHAPTER I. 
OF TETANUS. 

1257.] T3 OTH Nosologists and practical writers have 
Xj distinguished Tetanic complaints into the 
several species of Tetanus, Opisthotonos, and Empros- 
thotonos ; and I have in my Nosology put the Trismus, 
or Locked Jaw, as a genus distinct from the Tetanus. 
All this, however, I now judge to be improper; and am 
of opinion that all the several terms mentioned denote, 
and are applicable only to, different degrees of one and 
the same disease ; the history and cure of which I shall en- 
deavor to deliver in this chapter. 

1258.] Tetanic complaints may, from certain causes, oc- 
cur in every climate that we are acquainted with ; but they 
occur most frequently in the warmest climates, and most 
commonly in the warmest seasons of such climates. These 



PRACTICE OF PHYSIC. 395 

complaints affect all ages, sexes, temperaments, and com- 
plexions. The causes from whence they commonly pro- 
ceed, are cold and moisture applied to the body while it is 
Verv warm, and especially the sudden vicissitudes of heat 
and cold. Or, the disease is produced by punctures, la- 
cerations, or other lesions of nerves in any part of the bo- 
dy. There are, probably some other causes of this dis- 
ease ; but they are neither distinctly know.n, nor well ascer- 
tained. Though the causes mentioned do, upon occasion, 
affect all sorts of persons, they seem however to attack 
persons of middle age more frequently than the older or 
younger, the male sex more frequently than the female, 
and the robust and vigorous more frequently than the 
weaker. 

1259.] If the disease proceed from cold, it commonly 
comes on in a few days after the application of such cold ; 
but, if it arise from a puncture or other lesion of a nerve, 
the disease does not commonly come on for many days 
after the lesion has happened, very often when there is 
neither pain nor uneasiness remaining in the wounded or 
hurt part, and very frequently when the wound has been 
entirely healed up. 

1260.] The disease sometimes comes on suddenly to a 
violent degree, but more generally it approaches by slow 
degrees to its violent state. In this case it comes on with 
a sense of stiffness in the back part of the neck, which, 
gradually increasing, renders the motion of the head dif- 
ficult and painful. As the rigidity of the neck comes on 
and increases, there is commonly at the same time a sense 
of uneasiness felt about the root of the tongue ; which by- 
degrees, becomes a difficulty of swallowing, and at length 
an entire interruption of it. While the rigidity of the 
neck goes on increasing, there arises a pain, often violent, 
at the lower end of the sternum, and from thence shooting 
into the back. When this pain arises, all the muscles of 
the neck, and particularly those of the back part of it, are 
immediately affected with spasm, pulling the head strongly 
backwards. At the same time, the muscles that pull up 
the lower jaw, which upon the first approaches of the dis- 
ease were affected with some spastic rigidity, are now ge- 
nerally affected with more violent spasm, and set the teeth 
so closely together that they do not admit of the smallest 
opening. 

This is what has been named the Locked Jaw, and i* 



396 PRACTICE OF PHYSIC. 

often the principal part of the disease. When the disease 
has advanced thus far, the pain at the bottom of the sternum 
returns very frequently ; and with it the spasms of the hind 
neck and lower jaw are renewed with violence and much 
pain. As the disease thus proceeds, a greater number of 
muscles come to be affected with spasms. After those of 
the neck, those along the whole of the spine become affect- 
ed, bending the trunk of the body strongly backwards ; and 
this is what has been named the Opisthotonos. 

In the lower extremities, both the flexor and extensor 
muscles are commonly at the same time affected, and keep 
the limbs rigidly extended. Though the extensors of the 
head and back are usually the most strongly affected, yet 
the flexors, or those muscles of the neck that pull the head 
forward, and the muscles that should pull down the lower 
jaw are often at the same time strongly affected with spasm. 
During the whole of the disease, the abdominal muscles 
are violently affected with spasm, so that the belly is strong- 
ly retracted, and feels hard as a piece of board. 

At length the flexors of the head and trunk become so 
strongly affected as to balance the extensors, and to keep 
the head and trunk straight, and rigidly extended, incapa- 
ble of being moved in any way ; and it is to this state the 
term of Tetanus has been strictly applied. At the same 
time, the arms, little affected before, are now rigidly ex- 
tended ; the whole of the muscles belonging to them being 
affected with spasms, except those that move the fingers, 
which often to the last retain some mobility. The tongue 
also long retains its mobility ; but at length it also becomes 
affected with spasms, which, attacking certain of its mus- 
cles only, often thrusts it violently out between the teeth. 

At the height of the disease, every organ of voluntary 
motion seems to be affected ; and amongst the rest, the 
muscles of the face. The forehead is drawn up into fur- 
rows, the eyes, sometimes distorted, are commonly rigid, 
and immoveable in their sockets ; the nose is drawn up, and 
the cheeks are drawn backwards towards the ears, so that 
the w!iole countenance expresses the most violent grinning. 
Under these universal spasms a violent convulsion com- 
monly comes on, and puts an end to life. 

1261. J These spasms are every where attended with most 
violent pains. The utmost violence of spasm is however, 
not constant ; but, after subsisting for a minute or two, 
the muscles admit of some remission of their contraction, 



PRACTICE OF PHYSIC. 397 

although of no such relaxation as can allow the action of 
their antagonists. This remission of contraction gives also 
some remission of pain ; but neither is of long duration. 
From time to time, the violent conti*actions and pains are 
renewed sometimes every ten or fifteen minutes, and that 
often without any evident exciting cause. But such excit- 
ing causes frequently occur ; for almost every attempt to 
motion, as attempting a change of posture, endeavoring to 
swallow, and even to speak, sometimes gives occasion to a 
renewal of the spasms over the whole body. 

1262.] The attacks of this disease are seldom attended 
with any fever. When the spasms are general and violent, 
the pulse is contracted, hurried, and irregular ; and the re- 
spiration is affected in like manner: but, during the remis- 
sion, both the pulse and respiration usually return to their 
natural state. The heat of the body is commonly not in- 
creased ; frequently the face is pale, with a cold sweat up- 
on it ; and very often the extremities are cold, with a cold 
sweat over the whole body. When, however, the spasms 
are frequent and violent, the pulse is sometimes more full 
and frequent than natural : the face is flushed, and a warm 
sweat is forced out over the whole body. 

1263.] Although fever be not a constant attendant of 
this disease, especially when arising from a lesion of nerves ; 
yet, in those cases proceeding from cold, a fever sometimes 
has supervened, and is said to have been attended with in- 
flammatory symptoms. Blood has been often drawn in 
this disease, but it never exhibits any inflammatory crust; 
and all accounts seem to agree, that the blood drawn seems 
to be of a looser texture than ordinary, and that it docs not 
coagulate in the usual manner. 

1264.] In this disease the head is seldom affected with 
delirium, or even confusion of thought, till the last stage 
of it; when, by the repeated shocks of a violent distem- 
per, every function of the system is greatly disordered. 

1265.] It is no less extraordinary, that, in this violent 
disease, the natural functions are not either immediately 
or considerably affected. Vomitings sometimes appear 
early in the disease, but commonly they are not continued; 
and it is usual enough for the appetite of hunger to remain 
through the whole course of the disease ; and what food 
happens to be taken down, seems to be regularly enough 
digested. The excretions are sometimes affected, but not 
always. The urine is sometimes suppressed, or is voided 



398 PRACTICE OF PHYSIC. 

with difficulty and pain. The belly is costive : but, as 
we have hardly any accounts excepting of those cases in 
which opiates have been largely employed, it is uncertain 
whether the costivencss has been the effect of the opiates 
or of the disease. In several instances of this disease, a 
miliary eruption has appeared upon the skin ; but whether 
this be a symptom of the disease, or the effect of a cer- 
tain treatment of it, is undetermined. In the mean while, 
it has not been observed to denote either safety or danger, 
or to have any effect in changing the course of the dis- 
temper. 

1266.] This disease has generally proved fatal ; and this 
indeed may be justly supposed to be the consequence of its 
nature : but, as we know, that, till very lately, physicians 
were not well acquainted with a proper method of cure ; 
and that since a more proper method has been known and 
practised, many have recovered from this disease ; it may 
be therefore concluded, that the fatal tendency of it is not 
so unavoidable as has been imagined. 

In judging of the tendency of this disease, in particular 
cases, we may remark, that, when arising from lesions of 
the nerves, it is commonly more violent, and of more dif- 
ficult cure, than when proceeding from cold ; that the dis- 
ease which comes on suddenly, and advances quickly to a 
violent degree, is always more dangerous than that which 
is slower in its progress. Accordingly, the disease often 
proves fatal before the fourth day ; and, when a patient has 
passed this period, he may be supposed to be in greater 
safety, and in general the disease is the safer the longer it 
bas continued. It is however, to be particularly observed, 
that, even for many days after the fourth,' the disease con- 
tinues to be dangerous ; and, even after some considerable 
abatement of its force, it is ready to recur again with its 
former violence and danger. It never admits of any sudden, 
or what is called critical solution ; but always recedes by 
degrees only, and it is often very long before the whole of 
the symptoms disappear. 

1267.] From the history of the disease now described, it 
will be evident, that there is no room for distinguishing the 
tetanus, opisthotonos, and trismus, or locked jaw, as dif- 
ferent species of this disease, since they all arise from the 
same causes, and are almost constantly conjoined in the 
same person. I have no doubt that the emprosthotonos be- 
longs also to the same genus ; and as the ancients have fre- 



PRACTICE OF PHYSIC. 399 

•juently mentioned it, we can have no doubt of its having 
occurred : but, at the same time, it is certainly in these 
days a rare occurrence ; and, as I have never seen it, nor 
find any histories in which this particular state of the spasms 
is said to have prevailed, I cannot mention the other cir- 
cumstances which particularly attend it, and may distin- 
guish it from the other varieties of tetanic cumplaints. 

1268.] This disease has put on still a different form from 
any of those above mentioned. The spasms have been 
sometimes confined to one side of the body only, and which 
bend it strongly to that side. This is what has been named 
by Sauvages the Tetanus Lateralis, and by some late writ- 
ers the Pleurosthotonos. This form of the disease has cer- 
tainly appeared very seldom ; and, in any of the accounts 
given of it, I cannot find any circumstances that would lead 
me to consider it as any other than a variety of the species 
already mentioned, or to take further notice of it here. 

1269.] The pathology of this disease I cannot in any 
measure attempt ; as the structure of moving fibres, the 
state of them under different degrees of contraction, and 
particularly the state of the sensorium, as variously deter- 
mining the motion of the nervous power, are all matters 
very imperfectly, or not all, known to me. In such a situ- 
ation, therefore, the endeavoring to give any rules of prac- 
tice, upon a scientific plan, appears to me vain and fruit- 
less ; and towards directing the cure of this disease, we 
must be satisfied with having learned something useful from 
analogy, confirmed by experience 

1270.] When the disease is known to arise from the le- 
sion of a nerve in any part of the body, the first, and as I 
judge, the most important step to be taken towards the 
cure, is, by every possible means, to cut off that part from 
all communication with the sensorium, either by cutting 
through the nerves in their course, or perhaps by destroying, 
to a certain length, their affected part or extremity. 

1271.] When the cure of the disease is to be attempted 
by medicine, experience has taught us that opium has of- 
ten proved an effectual remedy ; but that, to render it such, 
it must be given in much larger quantities than have been 
employed in any other case ; and in these larger quantities, 
it may, in this disease, be given more safely than the body 
has been known to bear in any other condition. The prac- 
tice has been, to give the opium either in a solid or liquid 
form, not in any very large Jose at once, but in moderate 



400 PRACTICE OF PHYSIC. 

doses, frequently repeated, at the interval of one, two, 
three, or more hours, as the violenee of the symptoms seem 
to require.* Even when large quantities have been given 
in this way, it appears that the opium does not operate 
here in the same manner as in most other cases ; for, though 
it procure some remission of the spasms and pains, it 
hardly induces any sleep, or occasions that stupor, intoxi- 
cation, or delirium, which it often does in other circum- 
stances, when much smaller quantities only have been given. 
It is therefore very properly observed, that, in tetanic af- 
fections, as the opium shows none of those effects by which 
it may endanger life, there is little or no reason for being- 
sparing in the exhibition of it ; and it may be given, pro- 
bably should be given, as largely and as fast as the symp- 
toms of the disease may seem to demand. 

It is particularly to be observed, that though the first 
exhibition of the opium may have produced some remission 
of the symptoms, yet the effects of opium do not long con- 
tinue in the system; and this disease being for some time 
ready to recur, it is commonly very necessary, by the time 
that the effects of the opium given may be supposed to be 
wearing off, and especially upon the least appearance of 
the return of the spasms, to repeat the exhibition of the 
opium in the same quantities as before. This practice is 
to be continued while the disease continues to show any 
disposition to return ; and it is only after the disease has 
already subsisted for some time, and when considerable and 
long-continued remissions have taken place, that the doses 
of the opium may be diminished, and the intervals of ex- 
hibiting them be more considerable. 

1272.] The administering of opium in this manner, has 
in many cases been successful ; and probably would have 
been equally so in many others, if the opium had not been 

* Though the exhibition of opium in Tetanus has been the most universal practice, it must 
nevertheless be acknowledged, thai, in many, if not in must cases, it has been ineffectual. The 
disease, indeed, is in general fatal j but, as in most of the cases that terminated happily, opium 
i-as been given, as the author describes, either in large doses, or frequently repeated sm?U 
doses, we must necessarily conclude that the practice ought to be followed. I have seen only 
one case of Tetanus ; it proceeded from a wound which a carpenter received mi the wrist of 
bis left aim with a saw. The inflammation was violent : the stiffness of the neck at first ap- 
peared on the thud day, when the inflammation began to abate after bleeding, and the appli- 
cation of emollient poultices : the pulse was weak and small ; thirty drops of laudanum were 
given; the symptoms increased ; and, on the day following, the jaw became fixed. Thirly 
drops of laudanum were repeated ; and the symptoms abating within two hours after its exhi- 
bition, indicated a repetition of the dose, which, from its good effects, was a fourth time repeat- 
ed that same day. The wound suppurated; and the day following, with two doses of frrtr 
drops of laudanum, the symptoms of Tetanus wholly disappeared, but left the patient in a 
most debilitated state. A costiveness supervened, that was removed with the use of manna 
and Glauber's salts occasionally : the patient was nourished with rich broths and wine • but he 
did not recover hrs former strength till after %ix weeks, although the wound healed in half that 
time. 



PRACTICE OF PHYSIC. 401 

too sparingly employed, either from the timidity of practi- 
tioners, or from its exhibition being prevented by that in- 
terruption of deglutition which so often attends this disease. 
This latter circumstance directs, that the medicine should 
be immediately and largely employed upon the first ap- 
proach of the disease, before the diglutition becomes diffi- 
cult ; or that, if this opportunity be lost, the medicine, 
in sufficient quantity, and with due frequency, should be 
thrown into the body by glysters ; which, however, does 
not seem to have been hitherto often practised. 

1273.] It is highly probable, that, in this disease, the in- 
testines are affected with the spasm that prevails so much in 
other parts of the system ; and therefore that costiveness 
occurs here as a symptom of the disease.* It is probably 
also increased by the opium, which is here so largely em- 
ployed ; and, from whichever of these causes it arises, it 
certainly must be held to aggravate the disease, and that a 
relaxation of the intestinal canal will contribute to a relax- 
ation of the spasms elsewhere. This consideration directs 
the frequent exhibition of laxatives while the power of de- 
glutition remains, or the frequent exhibition of glysters 
when it does not ; and the good effects of both have been 
frequently observed. 

1274.] It has been with some probability supposed, that 
the operation of opium in this disease, may be much assist- 
ed by joining with it some other of the most powerful an- 
tispasmodics. The most promising are musk and camphor ; 
and some practitioners have been of opinion, that the for- 
mer has proved very useful in tetanic complaints. But, 
whether it be from its not having been employed of a ge- 
nuine kind, or in sufficient quantity, the great advantage 
and propriety of its use are not yet clearly ascertained. It 
appears to me probable, that analogous to what happens 
with respect to opium, both musk and camphor might be 
employed in this disease, in much larger quantities than 
they commonly have been in other cases. 

1275.] Warm bathing has been commonly employed as a 
remedy in this disease, and often with advantage ; but, so 
far as I know, it has not alone proved a cure ; and, in some 
cases, whether it be from the motion of the body here re- 
quired, exciting the spasms, or from the fear of the bath, 
which some persons were seized with, I cannot determine ; 
but it is allowed, that the warm bath hath in some cases 

• This symptom occurred in tbe case mentioned in the preceding note. 

3f 



402 PRACTICE OF PHYSIC. 

done harm, and even occasioned death. Partial fomenta- 
tions have been much commended, and, I believe, upon 
good grounds : and I have no doubt but that fomentations 
of the feet and legs, as we now usually apply them in fe- 
vers, might, without much stirring of the patient be very 
assiduously employed with advantage. 

1276.] Unctuous applications were very frequently em- 
ployed in this disease by the ancients : and some modern 
practitioners have considered them as very useful. Their 
effects, however, have not appeared to be considerable ; 
and, as a weak auxiliary only, attended with some incon- 
venience, they have been very much neglected by the Bri- 
tish practitioners. 

1277.] Bleeding has been formerly emploved in this dis- 
ease ; but of late it has been found prejudicial, excepting 
in a few cases, where, in plethoric habits, a fever has su- 
pervened. In general, the state of men's bodies in warm 
climates is unfavorable to blood-letting : and, if we may 
form indications from the state of the blood drawn out of 
the veins, the state of this in tetanic diseases would forbid 
bleeding in them. 

1278.] Blistering also has been formerly emploved in 
this disease ; but several practitioners assert, that ulisters 
are constantly hurtful, and they are now generally omitted. 

1279.] These are the practices that hitherto have been, 
generally employed ; but of late we are informed by seve- 
ral West-India practitioners, that in many instances they 
have employed mercury with great advantage. We are 
told, that it must be employed early in the disease ; that it 
is most conveniently administered by unction, and should 
be applied in that way in large quantities, so that the body 
may be soon filled with it, and a salivation raised, which 
is to be continued till the symptoms yield. Whether this 
method alone be generally sufficient for the cure of the dis- 
ease, or if it may be assisted by the use of opium, and re- 
quire this in a certain measure to be joined with it, I have 
not yet certainly learned. 

1280.] I have been further informed, that the tetanus, in 
all its different degrees, has been cured by giving internally 
the Pisselaeum Barbadense, or, as it is vulgarly called, the 
Barbadoes Tar. I think it proper to take notice of this 
here, although I am not exactly informed what quantities 
of this medicine are to be given, or in what circumstances 
of the disease it is most properly to be employed. 



PRACTICE OF PHYSIC. 403 

1281.] In the former edition of this work, among the 
remedies of tetanus I did not mention the use of cold bath- 
ing ; because, though I heard of this, I was not informed 
of such frequent employment of it as might confirm my 
opinion of its general efficacy ; nor was I sufficiently in- 
formed of the ordinary and proper administration of it. 
But now, from the information of many judicious practition- 
ers who have frequently employed it, I can say, that it is a 
remedy which in numerous trials has been found to be of 
great service in this disease ; and that, while the use of the 
ambiguous remedy of warm bathing is entirely laid aside, 
the use of cold bathing is over the whole of the West-Indie* 
commonly employed. The administration of it is some- 
times by bathing the person in the sea, or more frequently 
by throwing cold water from a bason or bucket upon the 
patient's body, and over the whole of it : when this is 
done, the body is carefully wiped dry, wrapped in blankets, 
and laid abed, and at the same time a large dose of an opiate 
is given. By these means a considerable remission of the 
symptoms is obtained ; but this remission, at first, does not 
commonly remain long, but returning again in a few hours, 
the repetition both of the bathing and the opiate becon*es 
necessary. By these repetitions, however, longer intervals 
of ease are obtained, and at length the disease is entirely 
cured ; and this even happens sometimes very quickly. I 
have only to add, that it does not appear to me, from any 
accounts I have yet had, that the cold bathing has been so 
frequently employed, or has been found so commonly suc- 
cessful in the cases of tetanus in consequence of wounds, 
as in those from the application of cold. 

1282.] Before concluding this chapter, it is proper for 
me to take some notice of that peculiar case of the tetanus, 
or trismus, which attacks certain infants soon after their 
birth, and has been properly enough named the Trismus 
Nascentium. From the subjects it affects, it seems to be 
a peculiar disease: for these are infants not above two 
weeks, and commonly before the}' are nine days, old ; in- 
somuch that, in countries where the disease is frequent, if 
children pass the period now mentioned, they are consider- 
ed as secure against its attacks. The symptom of it chiefly 
taken notice of, is the trismus, or locked jaw, which is by 
the vulgar improperly named the Falling of the Jaw. But 
this is not the only symptom, as, for the most part, it has 
all the same symptoms as the Opisthotonos and Tetanus 



404 PRACTICE OF PHYSIC, 

strictly so called, and which occur in the other varieties of 
tetanic complaints above described. Like the other va- 
rieties of tetanus, this is most frequent in warm climates, 
but it is not, like those arising from the application of cold, 
entirely confined to such warm climates, as instances of it 
have occurred in most of the northern countries of Europe. 
In these latter it seems to be more frequent in certain dis- 
tricts than in others ; but in what manner limited, I cannot 
determine. It seems to be more frequent in Switzerland 
than in France. I am informed of its frequently occurring 
in the Highlands of Scotland; but I have never met with 
any instance of it in the low country. The particular 
causes of it are not well known ; and various conjectures 
have been offered; but none of them are satisfying. It is 
a disease that has been almost constantly fatal ; and this, 
also, commonly in the course of a few days. The women 
are so much persuaded of its inevitable fatality, that they 
seldom or never call for the assistance of our art. This has 
occasioned our being little acquainted with the history of 
the disease, or with the effects of remedies in it. Analogy, 
however, would lead us to employ the same remedies that 
have proved useful in the other, cases of tetanus ; and the 
few experiments that are yet recorded, seem to approve of 
guch a practice. 



CHAPTER II. 
OF EPILEPSY. 

1283.] TN what sense I use the term Convulsion, I have 
JL explained above in 1256. 

The convulsions that affect the human body are in seve- 
ral respects various ; but I am to consider here only the 
chief and most frequent form in which they appear, and 
which is in the disease named Epilepsy. This may be de- 
nned, as consisting in convulsions of the greater part of the 
muscles of voluntary motion, attended with a loss of sense, 
and ending in a state of insensibility and seeming sleep. 

1284.] The general form or principal circumstances of 
this disease, are much the same in all the different persons 
whom it affects. It comes by fits, which often attack per- 
sons seemingly in perfect health ; and, after lasting for some 
time, pass off, anql leave the persons again in their usual 



PRACTICE OF PHYSIC. 405 

state. These fits are sometimes preceded by certain symp- 
toms, which to persons who have before experienced such 
a fit, may give notice of its approach, as we shall hereafter 
explain ; but even these preludes do not commonly occur 
long before the formal attack, which in most cases comes on 
suddenly without any such warning. 

The person attacked loses suddenly all sense and power, 
of motion ; so that, if standing, he falls immediately, or 
perhaps, with convulsions, is thrown to the ground. la 
that situation he is agitated with violent convulsions, va- 
riously moving his limbs and the trunk of his body. Com- 
monly the limbs on one side of the body are more violent- 
ly or more considerably agitated than those upon the other. 
In all cases the muscles of the face and eyes are much af- 
fected, exhibiting various and violent distortions of the 
countenance. The tongue is often affected, and thrust 
out of the mouth ; while the muscles of the lower jaw are 
also affected ; and, shutting the mouth with violence while 
the tongue is thrust out between the teeth, that is often 
grievously wounded. 

While these convulsions continue, there is commonly at 
the same time a frothy moisture issuing from the mouth. 
These convulsions have for some moments some re- 
missions, but are suddenly again renewed with great vio- 
lence. Generally, after no long time, the convulsions 
cease altogether ; and the person for some time remains 
without motion, but in a state of absolute insensibility, 
and under the appearance of a profound sleep. After 
some continuance of this seeming sleep, the person some- 
times suddenly, but for the most part by degrees only, 
recovers his senses and power of motion ; but without any 
memory of what had passed from his being first seized with 
the fit. During the convulsions, the pulse and respiration 
are hurried and irregular; but, when the convulsions cease, 
they return to their usual regularity and healthy state. 

This is the general form of the disease : and it varies 
only in different persons, or on different occasions in the 
same person, by the phenomena mentioned being more or 
less violent, or by their being of longer or shorter duration. 

1285.] With respect to the proximate cause of this dis- 
ease, I might say, that it is an affection of the energy of the 
brain, which, ordinarily under the direction of the will, is 
here, without any concurrence of it, impelled by preterna- 
tural causes. But I could go no farther : for, as to what in 



406 PRACTICE OF PHYSIC, 

the mechanical condition of the brain in the ordinary exer- 
tions of the will, I have no distinct knowledge; and there- 
fore must be also ignorant of the preternatural state of the 
same energy of the brain under the irregular motions here 
produced. To form, therefore, the indications of a cure from 
a knowledge of the proximate cause of this disease, I must 
not attempt, but, from a diligent attention to the remote cau- 
ses which first induce and occasionally excite the disease, I 
think we may often obtain some useful directions for its cure. 
It shall therefore be my business now to point out and enu- 
merate these remote causes as well as I can. 

1286.] The remote causes of epilepsy may be considered 
as occasional or predisponent. There are, indeed, certain 
remote causes which act independently of any predisposi- 
tion ; but, as we cannot always distinguish these from the 
others, I shall consider the whole under the usual titles of 
Occasional or Predisponent. 

1287.] The occasional causes may, I think, be properly 
referred to two general heads ; the first being of those which 
seem to act by directly stimulating and exciting the energy 
of the brain ; and the second, of those which seem to act by 
weakening the same. With respect to both, for the bre- 
vity of expressing a fact, without meaning to explain the 
manner in which it is brought about, I shall use the terms 
of Excitement and Collapse. And though it be true, that 
with respect to some of the causes I am to mention, it may 
be a little uncertain whether they act in the one way or the 
other, that does not render it improper for us to mark, with 
respect to others, the mode of their operating, wherever we 
can do it clearly, as the doing so may often be of use in di- 
recting our practice. 

1288.] First, then, of the occasional causes acting by 
excitement: they are either such as act immediately and 
directly upon the brain itself; or those which are first ap- 
plied to the other parts of the body, and are from thence 
communicated to the brain. 

1289.] The causes of excitement immediately and di- 
rectly applied to the brain, may be referred to the four 
heads of, 1. Mechanical Stimulants; 2. Chemical Stimu- 
lus; 3. Mental Stimulants; and, 4. The peculiar Stimu- 
lus of Over Distention. 

1290] The mechanical stimulants may be, wounding 
instruments penetrating the cranium, and entering the sub- 
stance of the brain ; or splinters of a fractured cranium, 



PRACTICE OF PHYSIC. 407 

operating in the same manner ; or sharp pointed ossifica- 
tions, cither arising from the internal surface of the cranium, 
or formed in the membranes of the brain. 

1291.] The chemical stimulants (1289.) may be fluids 
from various causes lodged in certain parts of the brain, and 
become acrid by stagnation or otherwise. 

1292.] The mental irritations acting by excitement, are, 
all violent emotions of the active kind, such as joy and an- 
ger. The first of these is manifestly an exciting power, 
acting strongly, andrimmediately, on the energy of the brain. 
The second is manifestly, also, a power acting in the same 
manner. But it must be remarked, that it is not in this man- 
ner alone anger produces its effects : for it acts, also, strong- 
ly on the sanguiferous system, and may be a means of giv- 
ing the stimulus of over-distention ; as, under a fit of anger, 
the blood is impelled into the vessels of the head with vio- 
lence, and in a larger quantity. 

1293.] Under the head of Mental Irritations, is to be 
mentioned, the sight of persons in a fit of epilepsy, which 
has often produced a fit of the like kind in the spectator. 
It may, indeed, be a question, Whether this effect be im- 
putable to the horror produced by a sight of the seemingly 
painful agitations of the limbs, and of the distortions in the 
countenance of the epileptic person ; or if it may be ascrib- 
ed to the force of imitation merely? It is possible, that hor- 
ror may sometimes produce the effect : but certainly much 
may be imputed to that propensity to imitation, at all times 
so powerful and prevalent in human nature : and so often 
operating in other cases of convulsive disorders, which do 
not present any spectacle of horror. 

1294.] Under the same head of Mental Irritation, I think 

J)roper to mention as ail instance of it, the Epilepsia Simu- 
ata, or the Feigned Epilepsy, so often taken notice of. Al- 
though this, at first, may be entirely feigned, I have no 
doubt but that the repetition renders it at length real. The 
history of Quietism and of Exorcisms leads me to this opi- 
nion : and which receives a confirmation from what we know 
of the power of imagination, in renewing epileptic and 
hysteric fits. 

1295.] I come now to the fourth head of the irritations 
applied immediately to the brain, and which I apprehend 
to be that of the Over Distention of the blood-vessels in. 
that organ. That such a cause operates in producing epi- 
lepsy, is probable from this, that the dissections of persons 



408 PRACTICE OF PHYSIC. 

dead of epilepsy, has commonly discovered the marks of a 
previous congestion in the blood-vessels of the brain. 
This, perhaps may be supposed the effect of the fit which 
proved fatal : but that the congestion was previous thereto, 
is probable from the epilepsy being so often joined with 
headach, mania, palsy, and apoplexy; all of them dis- 
eases depending upon a congestion in the vessels of the 
brain. The general opinion receives also comfirmation 
from this circumstance, that, in the brain of persons dead 
of epilepsy, there have been often fourftl tumors and effu- 
sions, which, though seemingly not sufficient to produce 
those diseases which depend on the compression of a con- 
siderable portion of the brain, may, however, have been 
sufficient to compress so many vessels as to render the 
others upon any occasion of a more than usual turgescence, 
or impulse of the blood into the vessels of the brain more 
liable to an over distention. 

1296.] These considerations alone might afford founda- 
tion for a probable conjecture with respect to the effects of 
over distention. But the opinion does not rest upon con- 
jecture alone. That it is also founded in fact, appears from 
hence, that a plethoric state is favorable to epilepsy ; and 
that every occasional turgescence, or unusual impulse of 
the blood into the vessels of the brain, such as a fit of an- 
ger, the heat of the sun, or of a warm chamber, violent 
exercise, a surfeit, or a fit of intoxication, are frequently 
the immediate exciting causes of epileptic fits. 

1297.] 1 venture to remark further, that a piece of theo- 
ry may be admitted as a confirmation of this doctrine. As 
I have formerly maintained, that a certain fulness and ten- 
sion of the vessels of the brain is necessary to the support 
of its ordinary and constant energy, in the distribution of 
the nervous power ; so it must be sufficiently probable, 
that an over distention of these blood-vessels may be a 
cause of violent excitement. 

1298.] We have now enumerated the several remote or 
occasional causes of epilepsy, acting by excitement, and 
acting immediately upon the brain itself. Of the causes 
acting by excitement, but acting upon other parts of the 
body, and from thence communicated to the brain, they 
are all of them impressions producing an exquisite or hio-h. 
degree either of pleasure or pain. 

Impressions which produce neither the one nor the other^ 
have hardly any such effects ; unless when such impressions 



PRACTICE OF PHYSIC. 409 

are in a violent degree, and then their operations may be con- 
sidered as a mode of pain. It is, however, to be remarked, 
that aU strong impressions which are sudden and surprising, 
or, in other words, unforeseen and unexpected, have fre- 
quently the effect of bringing on epileptic fits. 

1299.] There are certain impressions made upon different 
parts of the body, which as they often operate without 
producing any sensation, so it is uncertain to what head 
they belong: but it is probable that the greater part of them 
act by excitement, and therefore fall to be mentioned here. 
The chief instances are, the teething of infants; worms; 
acidity or other acrimony in the alimentary canal ; calculi 
in the kidneys; acrid matter in abscesses or ulcers; or acri- 
mony diffused in the mass of blood, as in the case of some 
contagions. 

1300.] Physicians have found no difficulty in compre- 
hending how direct stimulants, of a certain force, may ex- 
cite the action of the brain, and occasion epilepsy : but they 
have hitherto taken little notice of certain causes which ma- 
nifestly weaken the energy of the brain, and act, as I speak, 
by collapse. These, however, have the effect of exciting 
the action of the brain in such a manner as to occasion epi- 
lepsy. I might upon this subject, speak of the vis medica- 
trix natur<e; and there is a foundation for the term ; but, 
as I do not admit the Stahlian doctrine of an administering 
soul, I make use of the term only as expressing a fact, and 
would not employ it with the view of conveying an ex- 
planation of the manner in which the powers of collapse 
mechanically produce their effects. In the mean time, 
however, I maintain, that there are certain powers of 
collapse which in effect prove stimulants, and produce 
epilepsy. 

l.'iOl.] That there are such powers, which maybe term- 
ed Indirect Stimulants, I conclude from hence, that several 
of the causes of epilepsy are such as frequently produce 
syncope, which we suppose always to depend upon causes 
weakening the energy of the brain, (1176.) It may give 
some difficulty to explain, why the same causes sometimes 
occasion syncope, and sometimes occasion the reaction tliat 
appears in epilepsy; and I shall not attempt to explain it: 
but this, I think, does not prevent my supposing that the 
operation of these causes is by collapse. That there are 
such causes producing epilepsy, will, I think, appear very 

3g 



410 PRACTICE OF PHYSIC. 

clearly from the particular examples of them I am now to 
mention. 

1302.] The first to be mentioned, which I suppose to be 
of this kind, is hemorrhagy, whether spontaneous or artifi- 
cial. That the same hemorrhagy which produces syncope, 
often at the same time produces epilepsy, is well known ; 
and from many experiments and observations it appears, 
that hemorrhagies occurring to such a degree as to prove 
mortal, seldom do so without first producing epilepsy. 

1303.] Another cause acting, as I suppose, by collapse, 
and therefore sometimes producing syncope, and sometimes 
epilepsy, is terror ; that is, the fear of some great evil sud- 
denly presented. As this produces at the same time a sud- 
den and considerable emotion, (1 180.) so it more frequently 
produces epilepsy than syncope. 

1304.] A third cause acting by collapse, and producing 
epilepsy, is horror ; or a strong aversion suddenly raised by 
a very disagreeable sensation, and frequently arising from 
a sympathy with the pain or danger of another person. As 
horror is often a cause of syncope, there can be no doubt 
of its manner of operating in producing epilepsy ; and it 
may perhaps be explained upon this general principle, That 
as desire excites action and gives activity, so aversion re- 
strains from action, that is, weakens the energy of the brain ; 
and, therefore, that the higher degrees of aversion may have 
the effects of producing syncope or epilepsy. 

1305.] A fourth set of the causes of epilepsy, which I 
6uppose also to act by collapse, are certain odors, which oc- 
casion either syncope or epilepsy ; and, with respect to the 
former, I have given my reasons ( 1 182.) for supposing odors 
in that case to act rather as disagreeable than as sedative. 
These reasons will, I think, also apply here ; and perhaps 
the whole affair of odors might be considered as instances of 
the effect of horror, and therefore belonging to the last head. 

1306.] A fifth head of the causes producing epilepsy by 
collapse, is the operation of many substances considered, and 
for the most part properly considered, as poisons. Many 
of these, before they prove mortal, occasion epilepsy. This 
effect, indeed, may, in some cases be referred to the inflam- 
matory operation which they sometimes discover in the sto- 
mach, and other parts of the alimentary canal ; but, as the 
greater part of the vegetable poisons show chiefly a narcotic, 
or strongly sedative power, it is probably by this power that 



PRACTICE OF PHYSIC. 411 

they produce epilepsy, and therefore belong to this head of 
the causes acting by collapse. 

1307.J Under the head of the remote causes producing 
epilepsy, we must now mention that peculiar one whose 
operation is accompanied with what is called the Aura Epi- 
Uptica.- This is a sensation of something moving in some 
part of the limbs or trunk of the body, and from thence 
creeping upwards to the head ; and when it arrives there, 
the person is immediately deprived of sense, and falls into 
an epileptic fit. This motion is described by the persons 
feeling it sometimes as a cold vapor, sometimes as a fluid 
gliding, and sometimes as the sense of a small insect creep- 
ing along their body ; and very often they can give no dis- 
tinct idea of their sensation, otherwise than as in general of 
something moving along. This sensation might be sup- 
posed to arise from some affection of the extremity or other 
part of a nerve acted upon by "Some irritating matter ; and 
that the sensation, therefore, followed the course of such a 
nerve : but I have never found it following distinctly the 
course of any nerve ; and it generally seems to pass along 
the teguments. It has been found in some instances to arise 
from something pressing upon or irritating a particular nerve, 
and that sometimes in consequence of contusion or wound : 
but instances of these are more rare : and the more common 
consequence of contusions and wounds is a tetanus. This 
latter effect wounds produce, without giving any sensation 
of an aura or other kind of motion proceeding from the 
wounded part to the head ; while on the other hand, the 
aura producing epilepsy, often arises from a part which had 
never been affected with wound or contusion, and in which 
part the nature of the irritation can seldom be discovered. 
It is natural to imagine that this aura epileptica is an evi- 
dence of some irritation or direct stimulus acting in the part, 
and from thence communicated to the brain, and should 
therefore have been mentioned among the causes acting by 
excitement ; but the remarkable difference that occurs in 
seemingly like causes producing tetanus, give some doubt 
on this subject. 

1308.] Having now enumerated the occasional causes of 
epilepsy, I proceed to consider the predisponent. As so 
many of the above mentioned causes act upon certain per- 
sons, and not at all upon others, there must be supposed in 
those persons a predisposition to this disease : but in what 
this predisposition consists, 1* not easily to be ascertained. 



412 PRACTICE OF PHYSIC. 

1309.] As many of the occasional causes are weak impres- 
sions, and are applied to most persons with little or no effect, 
I conclude, that the persons affected by those causes are 
more easily moved than others ; and therefore that, in this 
case, a certain mobility gives the predisposition. It will, 
perhaps, make this matter clearer, to show, in the first place, 
that there is a greater mobility of constitution in some per- 
sons than in others. 

1310.] This mobility appears most clearly in the state of 
the mind. If a person is readily elated by hope, and as rea- 
dily depressed by fear, and passes easily and quickly from the 
one state to the other ; and if he is easily pleased, and prone 
to gaiety, and as easily provoked to anger, and rendered 
peevish ; if liable, from slight impressions, to strong emo- 
tions, but tenacious of none; this is the boyish temperament 
qui colligit ac ponit tram temere, et mutater in horas ; this 
is the varium el mutabile fcemina ; and, both in the boy 
and woman, every one perceives and acknowledges a mo- 
bility of mind. But this is necessarily connected with an 
analogous state of the brain ; that is, with a mobility, in 
respect of every impression, and therefore liable to a ready 
alteration of excitement and collapse, and of both to a con- 
siderable degree. 

1311.] There is, therefore, in certain persons, a mobility 
of constitution, generally derived from the state of original 
stamina, and more exquisite at a certain period of life than 
at others ; but sometimes arising from, and particularly 
modified by, occurrences in the course of life. 

1312.] This mobility consists in a greater degree of either 
sensibility or irritability. These conditions, indeed, phy- 
sicians consider as so necessarily connected that the consti- 
tution with respect to them, may be considered as one and 
the same : but I am of opinion that they are different ; and 
that mobility may sometimes depend upon an increase of 
the one and sometimes on that of the other. If an action 
excited, is, by repetition rendered more easily excited, and 
more vigorously performed, I consider this as an increase of 
irritability only. I go no further on this subject here, as it 
was only necessary to take notice of the case just now men- 
tioned, for the purpose of explaining why epilepsy, and con- 
vulsions of all kinds, by being repeated, are more easily 
excited, readily become habitual, and are therefore of more 
difficult cure. 

1313.] However we may apply the distinction of sensi- 



PRACTICE OF PHYSIC. 413 

bility and irritability, it appears that the mobility, which is 
the predisponent cause of epilepsy, depends more particu- 
larly upon debility, or upon a plethoric state of the body. 

1314.] What share debility, perhaps by inducing sensi- 
bility, has in this matter, appears clearly from hence, that 
children, women, and other persons of manifest debility, 
are the most frequent subjects of this disease. 

1315.] The effects of a plethoric state in disposing to 
this disease appears from hence, that plethoric persons are 
frequently the subjects of it : that it is commonly excited, 
as I have said above, by the causes of any unusual tumes- 
cence of the blood ; and that it has been frequently cured 
by diminishing the plethoric state of the bouy. 

That a plethoric state of the body should dispose to this 
disease, we may understand from several considerations. 
lst t Because a plethoric state implies, for the most part a 
laxity of the solids, and therefore some debility in the mov- 
ing fibres. 2dly, Because, in a plethoric state, the tone of 
the moving fibres depends more upon their tension, than 
upon their inherent power : and as their tension depends 
upon the quantity and impetus of the fluids in the blood- 
vessels, which are very changeable, and by many causes 
frequently changed, so these frequent changes must give a 
mobility to the system. Zdly^ Because a plethoric state is 
favorable to a congestion of blood in the vessels of the brain, 
it must render these more readily affected by every general 
turgescence of the blood in the system, and therefore more 
especially dispose to this disease. 

1316.] There is another circumstance of the body dis- 
posing to epilepsy, which I cannot so well account for : and 
that is, the state of sleep : but whether I can account for it 
or not, it appears, in fact, that this state gives the dispo- 
sition I speak of ; for, in many persons liable to this dis- 
ease, the fits happen only in the time of sleep, or imme- 
diately up6*n the person's coming out of it. In a case re- 
lated by De Haen, it appeared clearly, that the disposition 
to epilepsy depended entirely upon the state of the body in 
sleep.* 

1317.] Having thus considered the whole of the remote 

• This was a very singular case. The chief circumstances in it were, that the boy was more 
liable to the paroxysm* when lying and asleep, than when sitting up and awake. This peculia- 
rity was not observed till the disease had been of some standing ; and, on a more minute atten- 
tion, the paroxysms were found to be more frequent when the patient was in a peculiar state 
of Bleeping, namely, when he was drowsy, or when he snored in his sleep, the paroxysms were 
■BOre frequent llun when he enioy^d an easy and quiet sleep. A natural, quiet, and easy sleep, 
was procured by the use of opium ; and, in a short time, the disease was perfectly cured , but 
the boy died afterwards, in consequence of a tumor in the Kroin. 



414 PRACTICE OF PHYSIC. 

causes of epilepsy, I proceed to treat of its cure, as I hare 
said it is from the consideration of those remote causes only 
that we can obtain any directions for our practice in this 
disease.* I begin with observing, that as the disease may be 
considered as sympathic or idiopathic, I must treat of these 
separately, and judge it proper to begin Avith the former. 

I31S.] When this disease is truly sympathic, and de- 
pending upon a primary affection in some other part of the 
body, such as acidity or worms in the alimentary canal, 
teething, or other similar causes, it is obvious, that such 

{>rimary affections must be removed for the cure of the epi- 
epsy ; but it is not our business here to say how these pri- 
mary diseases are to be treated. 

1319.] There is, however, a peculiar case of sympathic 
epilepsy ; that is, the case accompanied with the aura epi- 
Itptica, as described in 1307, in which, though we can 
perceive by the aura epiltptica arising from a particular part, 
that there is some affection in that part ; yet, as in many 
such cases we cannot perceive of what nature the affection 
is, I can only offer the following general directions. 

1st, When the part can with safety be entirely destroyed, 
we should endeavor to do so by cutting it out, or by de- 
stroying it by the application of an actual or potential cau- 
tery. 

2dly, When the part cannot be properly destroyed, that 
we should endeavor to correct the morbid aHection in it by 
blistering, or by establishing an issue upon the part. 

Zdly, When these measures cannot be executed, or do 
not succeed, if the disease seems to proceed from the ex- 
tremity of a particular nerve which we can easily come at 
in its course, it will be proper to cut through that nerve, 
as before proposed on the subject of tetanus. 

4thlj/, When it cannot be perceived that the aura arise* 

• Other causes of Epilepsy are enumerated by medical writers, which the author, for the sake 
•f brevity, left unnoticed. Cases hjve occurred in which the epilepsy seem* t« have proceeded 
from an hereditary taint. Quicksilver, either accidentally or intentionally anpl.ed, has been 
frequently found to produec epi epsy. Persons employed 'in gilding ol ineials are of en seized 
with tremblings of the hanOs, with pai>y, and with epilepsy, winch can be attributed to nothing 
else than the absorption of die vapour, of mercury used in ihe operation, which is as follows ; 
the piece of metal to be gill is first well cleaned and polished ; some mercury shaken with aqua- 
fortis is spread upon it, till the surface appears ail over as wiite as silver; being then heated 
and retouched in those parts that have escaped the mixture, an amalgama ot mercury and jold ll 
laid on it ; the heat softening the amalgam 1, makes it spread more unilormly , and the inter- 
vention of the mercury and a.pja forti. mnkes it adhere more firmly. The piece thus covered 
wjth the almalgama is placed on a convenient s ipport, ovei a charcoal fire ; and examined, from 
tune to time, as the mercury evaporates, that, if any deficiencies appear they may be supplied 
with a little more of the amalgaina before the operation is compleied This process necessarily 
exposes the artist to the fumes of the mercury. 

Van Swieten says that he has seen skulls, in the dipploe of which globules o r mercury mani- 
festly appeared; and he thinks it probable that the mercury maj possibij be thrown out into 
the cavities of the brain itself, and produce much mischief. Venery, when excessive, has been 
♦numerated among tbe causes of epilepsy by Boerbaave, but on what autUority seems uncertain. 



PRACTICE OF PHYSIC. 415 

from any precise place or point, so as to direct to the above- 
mentioned operations ; but, at the same time, Ave can per- 
ceive its progress along the limb ; it frequently happens that 
the epilepsy can be prevented by a ligature applied upon 
the limb, above the part from which the aura arises ; and 
this is always proper to be done, both because the prevent- 
ing a fit breaks the habit of the disease, and because the 
frequept compression renders the nerves less fit to propagate 
the aura. 

1320.] The cure of idiopathic epilepsy, as I have said 
above, is to be directed by our knowledge of the remote 
causes. There are therefore two general indications to be 
formed. The first is, to avoid the occasional causes ; and 
the second is, to remove or correct the predisponent. 

This method, however, is not always purely palliative ; 
as in many cases the predisponent may be considered as the 
only proximate cause, so our second indication may be of- 
ten considered as properly curative. 

1321.] From the enumeration given above, it will be 
manifest, that for the most part the occasional causes, so 
far as they are in our power, need only to be known, in or- 
der to be avoided; and the means of doing this will be suf- 
ficiently obvious. I shall here, therefore, offer only a few 
remarks. 

1 322.] One of the most frequent of the occasional causes 
is that of over distention, (1314.) which, so far as it de- 
pends upon a plethoric state of the fey stem, I shall say here- 
after how it is to be avoided. But as, not only in the ple- 
thoric, but in every moveable constitution, occasional tur- 
gescence is a frequent means of ' exciting epilepsy, the 
avoiding therefore of such turgescence is what ought to be 
most constantly the object of attention to persons liable to 
epilepsy. 

1323.] Another of the most frequent exciting causes of 
this disease are, all strong impressions suddenly mace up- 
on the senses; for as such impressions, in moveable con- 
stitutions, break in upon the usual force, velocity, and or- 
der of the motions of the nervous system, they thereby 
readily produce epilepsy. Such impressions therefore, and 
especially those which are suited to excite any emotion or 
passion of the mind, are to be most carefully guarded 
against by persons liable to epilepsy. 

1324.] In many cases of epilepsy, where the predispo- 
nent cause cannot be corrected or removed, the recurrence 



416 PRACTICE OF PHYSIC. 

of the disease can only be prevented, by the strictest atten- 
tion to avoid the occasional; and as the disease is often con- 
firmed by repetition and habit, so the avoiding the frequent 
recurrence of it is of the utmost importance toward its cure. 

These are the few remarks I have to offer with respect to 
the occasional causes; and must now observe, that, for 
the most part, the complete, or, as it is called, the Radical 
Cure, is only to be obtained by removing or correcting the 
predisponent cause. 

1325.] I have said above, that the predisponent cause 
of epilepsy is a certain mobility of the sensorium ; and that 
this depends upon a plethoric state of the system, or upon 
a certain state of the debility in it. 

1326.] How the plethoric state of the system is to be 
corrected, I have treated of fully above in (781. et. seq.) 
and I need not repeat it here. It will be enough to say, 
that it is chiefly to be done by a proper management of 
exercise and diet; and, with respect to the latter, it is par- 
ticularly to be observed here, that an abstemious course has 
been frequently found to be the most certain means of cur- 
ing epilepsy. 

1327.] Considering the nature of the matter poured out 
by issues, these may be supposed to be a constant means 
of obviating the plethoric state of the system ; and it is, per- 
haps, therefore, that they have been so often found useful 
in epilepsy. Possibly, also, as an open issue may be a 
means of determining 1 occasional turgescences to such 
places, and therefore of diverting them in some measure 
from their action upon the brain ; so also, in this manner, 
issues may be useful in epilepsy. 

1328.] It might be supposed that blood-letting would be 
the most effectual means of correcting the plethoric state 
of the system; and such it certainly proves when the ple- 
thoric state has become considerable, and immediately 
threatens morbid effects. It is therefore, in such circum- 
stances, proper and necessary : but as we have said above, 
that blood-letting is not the proper means of obviating a 
recurrence of the plethoric state, and, on the contrary, is 
often the means of favoring it ; so it is not a remedy advisa- 
ble in every circumstance of epilepsy. There is however, 
a case of epilepsy in which there is a periodical or occa- 
sional recurrence of the fulness and turgescence of the san- 
guiferous system, giving occasion to a recurrence of the 
disease. In such cases, when the means of preventing pie- 



PRACTICE OF PHYSIC. 417 

thora have been neglected, or may have proved ineffectual, 
it is absolutely necessary for the practitioner to watch the 
returns of these turgescences, and to obviate their effects 
by the only certain means of doing it, that is, by a large 
blood-letting. 

1329.] The second cause of mobility which we have as- 
signed, is a state of debility. If this is owing, as it frequent- 
ly is, to original conformation, it is perhaps not possible to 
cure it ; but when it has been brought on in the course of 
life, it possibly may admit of being mended ; and, in either 
case, much may be done to obviate and prevent its effects. 

1 330.] The means of correcting debility, so far as it can 
be done, are, The person's being much in cool air ; the 
frequent use of cold bathing ; the use of exercise, adapted 
to the strength and habits of the person ; and, perhaps, the 
use of astringent and tonic medicines. 

These remedies are suited to strengthen the inherent 
power of the solids or moving fibres : but as the strength 
of these depends also upon their tension, so when debility 
has proceeded from inanition, the strength may be restor- 
ed, by restoring the fulness and tension of the vessels by a 
nourishing diet; and we have had instances of the proprie- 
ty and success of such a practice. 

1331.] The means of obviating the effects of debility, 
and of the mobility depending upon it, are the use of tonic 
and antispasmodic remedies. 

The tonics are, fear, or some degree of terror; astrin- 
gents ; certain vegetable and metallic tonics ; and cold- 
bathing. 

1332.] That fear, or some degree of terror, may be of 
use in preventing epilepsy, we have a remarkable proof in 
Boerhaave's cure of the epilepsy, which happened in the 
Orphan- house at Haerlem. See Kauu Boerhaave's treatise, 
entitled Impetum Faciens, § 406. And we have met with 
several other instances of the same. 

As the operation of horror is in many respects analogous 
to that of terror, several seemingly superstitious remedies 
have been employed for the cure of epilepsy; and, if they 
have ever been successful, I think it must be imputed to 
the horror they had inspired.* 

* Drinking i draught of the blood of a gladiator just killed ; drinking a draught of water with 

a toad it the bottom of the jug; eating a piece of human iivc-r, or the marrow of the bones of 

the li tor; powder of the human skull ; or the moss that grows on it ; with a variety 

h abominable remedies, were formerly in great repute, and indeed komc of them are 

still retained in several foreign Pharmacopoeias. 

3h 



418 PRACTICE OF PHYSIC. 

1333.] Of the astringent medicines used for the cure of 
epilepsy the most celebrated is the viscus quercinus, which, 
when given in large quantities, may possibly be useful; 
but I believe it was more especially so in ancient times, 
when it was an object of superstition. In the few instances 
in which I have seen it employed it did not prove of any 
effect.* 

1334.] Among the vegetable tonics, the bitters are to be 
reckoned ; and it is by this quality that I suppose the orange- 
tree leaves to have been useful: but they are not always so. 

1335.] The vegetable tonic, which from its use in ana- 
logous cases is the most promising, is the Peruvian bark; 
this, upon occasion, has been useful, but has also often fail- 
ed. It is especially adapted to those epilepsies which recur 
at. certain periods, and which are at the same time without 
the recurrence of any plethoric state or turgescence of the 
blood ; and in such periodical cases, if the bark is employed 
some time before the expected recurrence, it may be use- 
ful ; but it must be given in large quantity, and as near to 
the time of the expected return as possible. 

1336.] The metallic tonics seem to be more powerful 
than the vegetable, and a great variety of the former have 
been employed. 

Even arsenic has been employed in the cure of epilepsy; 
and its use in intermittent fevers gives an analogy in its fa- 
vor. 

Preparations of tin have been formerly recommended in 
the cure of epilepsy, and in the cure of the analogous dis- 
ease of hysteria ; and several considerations render the vir- 
tues of tin, with respect to these diseases, probable: but 
I have had no experience of its use in such cases. 

A much safer metallic tonic is to be found in the prepara- 
tions of iron ; and we have seen some of them employed in 
the cure of epilepsy, but have never found them to be ef- 
fectual. This, however, I think, may be imputed to their 
not having been always employed in the circumstances of 
the disease, and in the quantities of the medicine, that were 
proper and necessary, f 

1337.] Of the metallic tonics, the most celebrated and the 
most frequently employed is copper, under various prepa- 
ration. What preparation of it may be the most effectual, 

* The dose of it was from half a drachm to a drachm in powder, or about an ounce in infu- 
sion. . 

•f Die method of using iron was described in a note on article 576. 



PRACTICE OF PHYSIC. 419 

I dare not determine ; but of late the cuprum ammoniacum 
has been frequently found successful.* 

1338.] Lately the flowers of zinc have been recommend- 
ed by a great authority as useful in all convukive disorders; 
but in cases of epilepsy, I have not hitherto found that me- 
dicine useful. f 

1339.] There have been of late some instances of the 
cure of epilepsy by the accidental use of mercury ; and if 
the late accounts of the cure of tetanus by this remedy are 
confirmed, it will allow us to think that the same may be 
adapted also to the cure of certain cases of epilepsy. 

1340.] With respect to the employment of any of the 
above mentioned tonics in this disease, it must be observed, 
that in all cases where the disease depends upon a constant 
or occasional plethoric state of the system, these remedies 
are likely to be ineffectual ; and if sufficient evacuations are 
not made at the same time, these medicines are likely to be 
very hurtful. 

1341.] The other set of medicines which we have men- 
tioned as suited to obviate the effects of the too great mo- 
bility of the system, are the medicines named antispasmodics. 
Of these there is a long list in the writers on the Materia 
Medica, and by these authors recommended for the cure of 
epilepsy. The greater part, however, of those taken from 
the vegetable kingdom, are manifestly inert and insignifi- 
cant.;!; Even the root of the wild valerian hardly supports 
its credit. 

1342.] Certain substances taken from the animal kingdom 
seem to be much more powerful : and of these the chief, 
and seemingly the most powerful, is musk ; which employed 
in its genuine state, and in due quantity, has often been an 
effectual remedy.§ 

* This was a favorite remedy of the author's. lie first introduced it into practice in this coun- 
try, and the preparation of it was inserted in the Edinburgh Pharmacopa-ia. 

Jt is employed i>v beginning with small closes of half a grain, and increasing them gradually 
to as much as the Itomach will bear. It is, however, like all preparations of copper, a very 
dangerous medicine, and ought to be used with caution. 

+ The great authority by which the flowers of zinc were recommended was Gaubius 
dangerous a medicine as the cuprum ammoniacum, and must be used with the same caution. 

t This is certainly true ; but it must be acknowledged that some of them are manifestly .iciive 
and useful, as the asafcetida, sagapenum, and other fetid gums. The pilule gummos i 
PharmacuiKTias are good formulae lor these museous medicines j and then being reputed ineltica 
ciousand insignificant seems to have arisen from their not having been grfen in sufficient 
doses. They may be given with safety to die quantity of two drachms in a day, in repeated 
doses of twenu ins each ; and, if they should happen to purge, this inconvenience 

may be prevented, b) adding a quarter or halt a gram of opium to each dose of the pills, os 
taking ten drops ol laudanum after each dose, as occasion may require. 

| Musk is more effectual when given in substance than in any preparation that has been at- 
n icn to thirty grains, aud frequently repeated. It may t«e 
pwdc into a bolus, as in the following formula : 

R. Mosch. gr. xv. 



420 PRACTICE OF PHYSIC. 

It is probable also, that the oleum animate, as it has been 
named, when in its purest state, and exhibited at a proper 
time, may be an effectual remedy.* 

1 343.] In many diseases, the most powerful antispasmo- 
dic is certainly opium; but the propriety of its use in epi- 
lepsy has been disputed among physicians. When the dis- 
ease depends upon a plethoric state in which bleeding may 
be necessary, the employment of opium is likely to be ve- 
ry hurtful: but, when there is no plethoric or inflammato- 
ry state present, and the disease seems to depend upon irri- 
tation or upon increased irritability, opium is likely to prove 
the most certain remedy. f Whatever effects in this and 
other convulsive disorders have been atributed to the hy- 
oscyamus, must probably be attributed to its possessing a 
narcotic power similar to that of opium. 

1 344.] With respect to the use of antispasmodics, it is to 
be observed, that they are always most useful, and perhaps 
only useful, when employed at a time when epileptic fits 
are frequently recurring, or near to the times of the acces- 
sion of fits which recur after considerable intervals. 

1345.] On the subject of the cure of epilepsy, I have on- 
ly to add, that as the disease in many cases is continued by 
the power of habit only, and that in all cases habit has a 
great share in increasing mobility, and therefore in continu- 
ing this disease ; so the breaking in upon such habit, and 
changing the whole habits of the system, is likely to be a 
powerful remedy in epilepsy. Accordingly, a considera- 
ble change of climate, diet, and other circumstances in the 
manner of life, has often proved a cure of this disease. | 

1346.] After treating of epilepsy, I might hear treat of 
particular convulsions, which are to be distinguished from 

Tere in mortar, marmor. cum 
Sacch. alb. B\. ; et adde 
Confect. cardiac. 3ss. 
M. f. bolus. 

I throe or 6 'ur time'; a-day. 
» Hie do>e oi tins oil > from twenty to thirty drops; .t is, however, seldom used. 

ihose ca^e •. in which sorrv upturns indicate the approach of the fit, opium 

■it a large do»e has sometimes pieveiitedit altogether; but most commonly, however, 
a dose greatl) lessens its violence. Two grains of opium in substauce, or sixty or seventy 
drops of laudanum, are large doses. 

t A fter all that has been said on this disease, we must acknowledge that we know but little of 

if true nature, and, consequently, no certain method of cure can be given. It has baffled the 

earliest ages of physic, and still remains to be one of those many 

d.sfases cnainly cure. Some species of it, indeed, are certainly curable but 

ire few, znd suchonlv as arc symptomatic, or arise from peculiar mechanical irritations. 

Sxperience has morecvo shown us. that the disease often exists without anv apparent irritation,' 

and without any cause oLiervable on dissection ; Much room is therefore left lor future inves- 

i we must at present content ourselves with the hope* that 

ame wftl unfold whet human ingenuity has not m be«a capable oi effecting. 



PRACTICE OF PHYSIC. 421 

epilepsy by their being more partial : that is, affecting cer- 
tain parts of the body only, and by their not being attended 
with a loss of sense, nor ending in such a comatose state as 
epilepsy always does. 

J 347.] Of such convulsive affections many different in- 
stances have been observed and recorded by physicians. But 
many of these have been manifestly sympathic affections, to 
be cured only by curing the primary disease upon which 
they depend, and therefore not to be treated of here: or, 
though they are such as cannot be referred to another dis- 
ease, as many of them however have not any specific cha- 
racter with which they occur in different persons, I must 
therefore leave them to be treated upon the general princi- 
ples I have laid down with respect to epilepsy, or shall lay 
down with respect to the following convulsive disorder ; 
which, as having very constantly in different persons a pecu- 
liar character, I think necessary to treat of more particularly. 



CHAPTER III. 
OF THE CHOREA OR DANCE OF ST. VITUS. 

1348.] r T"MJIS disease affects both sexes, and almost 

JL only young persons. It generally happens 

from the age of ten to that of fourteen years.* It comes 

on always before the age of puberty, and rarely continues 

beyond that period. 

1349.] It is chiefly marked by convulsive motions, some- 
what varied in different persons, but nearly of one kind in 
all ; affecting the leg and arm on the same side, and gene- 
rally on one side only. 

1350.] These convulsive motions commonly first affect 
the leg and foot. Though the limb be at rest, the foot is 
often agitated by convulsive motions, turning it alternately 
outwards and inwards. When walking is attempted, the 
affected leg is seldom lifted as usual in walking, but is drag- 
ged along as if the whole limb were paralytic ; and, when 
it is attempted to be lifted, this motion is unsteadily per- 
formed, the limb becoming agitated by irregular convulsive 
motions. 

1351.] The arm of the same side is generally affected at 

• I have seen it in a robust man of forty-two. This patient, aficr various ineffectual reme- 
dial had been used, wa« cund by strong electrical shocks directed through the whole body. 



422 PRACTICE OF PHYSIC. 

the same time ; and, even when no voluntary motion is at- 
tempted, the arm is frequently agitated with various con- 
vulsive motions. But especially when voluntary motions 
are attempted, these are not properly executed, but are va- 
riously hurried or interrupted by convulsive motions in a di- 
rection contrary to that intended. The most common in- 
stance of this is in the persons attempting to carry a cup 
of liquor to his mouth, when it is only after repeated efforts, 
interrupted by frequent convulsive retractions and devia- 
tions, that the cup can be carried to the mouth. 

1352.] It appears to me, that the will often yields to 
these convulsive motions, as to a propensity, and thereby 
they are often increased, while the person affected seems to 
be pleased with increasing the surprise and amusement 
which his motions occasion in the bystanders. 

1353.] In this disease the mind is often affected with some 
degree of fatuity ; and often shows the same varied, desul- 
tory, and causeless emotions which occur in hysteria. 

1354.] These are the most common circumstances of this 
disease ; but at times, and in different persons, it is varied 
by some difference in the convulsive motions, particularly 
by these affecting the head and trunk of the body. As in 
this disease there seem to be propensities to motion, so va- 
rious fits of leaping and running occur in the persons affect- 
ed ; and there have been instances of this disease, consist- 
ing of such convulsive motions, appearing as an epidemic 
in a certain corner of the country. In such instances, per- 
sons of different ages are affected, and may seem to make 
an exception to the general rule above laid down ; but still 
the persons are, for the most part, the young of both sexes, 
and of the more manifestly moveable constitutions. 

1355.] The method of curing this disease has been va- 
riously proposed. Dr. Sydenham proposed to cure it by 
alternate bleeding and purging. In some plethoric habits 
I have found some bleeding useful ; but in many cases I 
have found repeated evacuations, especially by bleeding, 
very hurtful. 

In many cases, I have found the disease, in spite of re- 
medies of all kinds, continue for many months ; but I have 
also found it often readily yield to tonic remedies, such as 
the Peruvian bark, and chalybeates. 

The late Dr. De Haen found several persons laboring 
under this disease cured by the application of electricity. 



PRACTICE OF PHYSIC. 42$ 



SECTION II. 

Of the Spasmodic Affections of the Vital Functions. 

CHAPTER IV.* 
OF THE PALPITATION OF THE HEART. 

1356.] r T , HE motion thus named is a contraction or 
JL systole of the heart, that is performed with 
more rapidity, and generally also with more force than 
usual, and when at the same time the heart strikes with more 
than usual violence against the inside of the ribs, produc- 
ing often a considerable sound. 

1357.] This motion, or palpitation, is occasioned by a 
great variety of causes, which have been recited with great 
pains by Mr. Senac and others ; whom, however, I cannot 
follow in all the particulars with sufficient discernment, 
and therefore shall here only attempt to refer all the several 
cases of this disease to a few general heads. 

1358.] The first is of those arising from the application 
of the usual stimulus to the heart's contraction ; that is, the 
influx of the venous blood into its cavities, being made 
with more velocity, and therefore, in the same time, in 
greater quantity than usual. It seems to be in this manner 
that violent exercise occasions palpitation. 

1359.] A second head of the cases of palpitation, is of 
those arising from any resistance given to the free and entire 
evacuation of the ventricles of the heart. Thus a ligature 
made upon the aorta occasions palpitations of the most vi- 
olent kind. Similar resistances, either in the aorta or pul- 
monary artery, may be readily . imagined ; and such have 
been often found in the dead bodies of persons who, during 
life, had been much affected with palpitations. 

To this head are to be referred all those cases of palpi- 
tation arising from causes producing an accumulation of 
blood in the great vessels near to the heart. 

1360.] A third head of the cases of palpitation, is of 
those arising from a more violent and rapid influx of the 
nervous power into the muscular fibres of the heart. It is in 
this manner that I suppose various causes acting in the brain, 

•Though I I'.ive thought it proper to divide this book into sections, I thinlc it necessary, for 
the convenience of references, to number the chapters now the beginning. Anther. 



V 



424 PRACTICE OF PHYSIC. 

and particularly certain emotions of the mind occasion pal- 
pitation. 

1361.] A fourth head of the cases of palpitation, is of 
those arising from causes producing a weakness in the action 
of the heart, by diminishing the energy of the brain -with 
respect to it. That such causes operate in producing pal- 
pitation, I presume from hence, that all the several causes 
mentioned above (im. et seq.) as in this manner produc- 
ing syncope, do often produce palpitation. It is on this 
ground that these two diseases are affections frequently oc- 
curring in the same person, as the same causes may occa- 
sion the one or the other, according to the force of the 
cause and mobility of the person acted upon. It seems to 
be a law of the human economy, that a degree of debility 
occurring in any function, often produces a more vigorous 
exertion of the same, or at least an effort towards it, and 
that commonly in a convulsive manner. 

I apprehend it to be the convulsive action, frequently 
ending in some degree of a spasm, that gives occasion to the 
intermittent pulse so frequently accompanying palpitation. 

1362.] A fifth head of the cases of palpitation may per- 
haps be of those arising from a peculiar irritability or mo- 
bility of the heart. This, indeed, may be considered as a 
predisponent cause only, giving occasion to the action of 
the greater part of the causes recited above. But it is pro- 
per to observe, that this predisposition is often the chief 
part of the remote cause; insomuch that many of the cau- 
ses producing palpitation would not have this effect but in 
persons peculiarly predisposed. This head, therefore, of 
the cases of palpitation, often requires to be distinguished 
from all the rest. 

1363.] After thus marking the several cases and causes 
of palpitation, I think it necessary, with a view to the cure 
of this disease, to observe, that the several causes of it may 
be again reduced to two heads. The first is, of those con- 
sisting in, or depending upon, certain organic affections of 
the heart itself, or of the great vessels immediately con- 
nected with it. The second is, of those consisting in, or 
depending upon, certain affections subsisting and acting in 
other parts of the body, and acting either by the force of 
the cause, or in consequence of the mobility of the heart. 

1364.] With respect to the cases depending upon the 
first set of causes, I must repeat here what I said with res- 
pect to the like cases of syncope, that 1 do not know any 



PRACTICE OF PHYSIC. 435 

means of curing them. They, indeed, admit of some pal- 
liation, first, by avoiding every circumstance that may 
hurry the circulation of the blood ; and, secondly, by every 
means of avoiding a plethoric state of the system, or any 
occasional turgescence of the blood. In many of these 
cases, blood-letting may give a temporary relief : but in 
so far as debility and mobility are concerned, in such cases 
this remedy is likely to do harm. 

1365.] With respect to the cases depending upon the 
other set of causes, they may be various, and require very 
different measures ; but I can here say in general, that 
these cases may be considered as of two kinds ; one de- 
pending upon primary affections in other parts of the body, 
and acting by the force of the particular causes ; and ano- 
ther depending upon a state of mobility in the heart itself. 
In the first of these, it is obvious, that the cure of palpita- 
tion must be obtained by curing the primary affection ; 
which is not to be treated of here. In the second, the cure 
must be obtained, partly by diligently avoiding the occa- 
sional causes, partly and chiefly by correcting the mobi- 
lity of the system, and of the heart in particular ; for doing 
which we have treated of the proper means elsewhere. 



CHAPTER V. 

OFDYSPNQ2A, OR DIFFICULT BREATHING. 

1366.] r I "*HE exercise of respiration, and the organs 
JL of it, have so constant and considerable a 
connection with almost the whole of the other functions 
and parts of the human body, that upon almost every oc- 
casion of disease, respiration must be effected. Accor- 
dingly, some difficulty and disorder in this function, are 
in fact symptoms very generally accompanying disease. 

1367.] Upon this account, the symptom of difficult 
breathing deserves a chief place and an ample considera- 
tion in the general system of Pathology ; but what share 
of consideration it ought to have in a treatise of Practice, 
1 find it difficult to determine. 

1368.] On this subject, it is in the first place, necessary 
to distinguish between the symptomatic and idiopathic af- 
fections ; that is, between those difficulties of breathing 
which are symptoms only of a more general affection, or of 

Si 



426 PRACTICE OF PHYSIC. 

a disease subsisting primarily in other parts than the organs 
of respiration, and that difficulty of breathing which de- 
pends upon a primary affection of the lungs themselves. 
The various cases of symptomatic dyspnoea 1 have taken 
pains to enumerate in my Methodical Nosology, and it 
will be obvious they are such as cannot be taken notice of 
here. 

1369.] In my Nosology I have also taken pains to point 
out and enumerate the proper, or at least the greater part 
of the proper, idiopathic cases of the dyspnoea : but from 
that enumeration it will, I think, readily appear, that few, 
and indeed hardly any, of these cases, will admit or require 
much of our notice in this place. 

1370.] The Dyspnoea Sicca* species 2d, the Dyspnoea 
Aerea,\ sp. 3d, the Dyspnoea Terrea,% sp. 4th, and Dysp- 
noea Thoracica,^ sp. 1th, are some of them with difficulty 
known, and are all of them diseases which in my opinion 
do not admit of cure. All, therefore, that can be said con- 
cerning them here is, that they may admit of some pallia- 
tion ; and this, I think, is to be obtained chiefly by avoid- 
ing a plethoric state of the lungs, || and every circumstance 
that may hurry respiration. 

1371.] Of the Dyspnoea Extrinseca,^ sp. Sth, I can 
say no more, but that these external causes marked in the 
Nosology, and perhaps some others that might have like 
effects, are to be carefully avoided ; or, when they have 
been applied, and their effects have taken place, the disease 
is to be palliated by the means mentioned in the last pa- 
ragraph. 

1372.] The other species, though enumerated as idio- 
pathic, can hardly be considered as such, or as requiring 
to be treated of here. 

The Dyspnoea Catar?~halis,** sp> 1st, may be considered 
as a species of catarrh, and is pretty certainly to be cured 
by the same remedies as that species of catarrh which de- 

* The definition, which the author gives of this species in his Nosology, is Dyspnoea cut* 
tussi pierumque sicca. It arises from various causes, some of which are extremely diflicult, if 
not impossible, to be discovered. 

+ The definition of this bpecies is ? Dyspnoea a minima quavis tempestatum mulatinne aucta. 

X It is defined Dyspnoea cum tussi materitm terream vel calculosam ejicienlt. This is some- 
times the expulsion of a gouty matter. 

i The definition of this species is, Dyspnoea a partibus thoracem cingentibus lacsis, vel male 
conformatis. 

is intention is most speedily obtained by occasioning bleeding. 

« It is defined Dyspnoea a causis extcinis manifest is. These causes are various, as exposure 
to dusts of different kinds, to metallic fumes, to vitiated air. to vapours of different kinds, &c 

** It is defined, Dyspucea cum tussi jrequentt mucum viscidum copiosum ejiciente. 



PRACTICE OF PHYSIC. 427 

pcnds rather upon the increased afflux of mucus to the 
bronchia:, than upon any inflammatory state in them.* 

The Dyspnoea Aguosa,f sp. 5th, is certainly to be consi- 
dered as a species of dropsy, and is to be treated by the 
same remedies as the other species of that disease. 

The Dyspnoea Pinguedinosa,% sp. 6th, is in like manner 
to be considered as a symptom or local effect of the Poly- 
sarcia, and is only to be cured by correcting the general 
fault of the system. § 

1 313.] From this view of those idiopathic cases of dysp- 
noea, which are perhaps all I could properly arrange un- 
der this title, it will readily appear that there is little room 
for treating of them here : but there is still one case of dif- 
ficult breathing, which has been properly distinguished from 
every otner under the title of Asthma; and as it deserves 
our particular attention, I shall here separately consider it. 



CHAPTER VI. 
OF ASTHMA. 

1374.] f T , HE term of asthma has been commonly ap- 
X plied by the vulgar, and even by many 
writers on the Practice of Physic, to every case of diffi- 
cult breathing, that is, to every species of Dyspnoea. 
The Methodical Nosologists, also, have distinguished Asth- 
ma from Dyspnoea chiefly, and almost solely, by the for- 
mer being the same affection with the latter, but in a high- 
er degree. Neither of these applications of the term seems 
to have been correct or proper. I am of opinion, that the 
term asthma may be most properly applied, and should 
be confined, to a case of difficult breathing that has pecu- 
liar symptoms, and depends upon a peculiar proximate 
cause, which I hope to assign with sufficient certainty. It 
is this disease I am now to treat of, and, and it is nearly 
what Practical Writers have generally distinguished from 
the other cases of difficult breathing, by the title of Spas- 
modic Asthma, or of Asthma convidskun: ; although, by 

• The remedies for this purpose are, emetics, sudoriues, and expectorants; formulae of which 
mav lie si-en in the notes on article 1065. 
■fit. ,oca cum urina parcn, et oedemata pedum, sine fluctuation* in pectart, 

eriiticit hydrothoracis signis. 
I It is defined, /H.pn<ra in hominibus v/ilde obtsis. 

ni exercise, si cmii:;, and brisk purges, will soon hare the desired 
#B/ct ; and the dueaie way be prevented by absteraiouk living. 



428 PRACTICE OF PHYSIC. 

not distinguishing it with sufficient accuracy from the 
other cases of Dyspnoea, they have introduced a great deal 
of confusion into their treatises on this subject. 

1375.] The disease I am to treat of, or the Asthma to 
be strictly so called, is often a hereditary disease. It* sel- 
dom appears very early in life, and hardly till the time of 
puberty, or after it. It affects both sexes, but most fre- 
quently the male. I have not observed it to be more fre- 
quent in one kind of temperament than in another; and it 
does not seem to depend upon any general temperament of 
the whole body, but upon a particular constitution of the 
lungs alone. It frequently attacks persons of a full habit: 
but it hardly ever continues to be repeated for some length 
of time without occasioningan emaciation of the whole body. 

1376.] The attacks of this disease are generally in the 
night-time, or towards the approach of night; but there 
are also some instances of their coming on in the course of 
the day. At whatever time they come on, it is for the most 
part suddenly, with a sense of tightness and stricture across 
the breast, and a sense of straitness in the lungs impeding 
inspiration. The person thus attacked, if in a horizontal 
situation is immediately obliged to get into somewhat of 
an erect posture, and requires a free and cool air. The 
difficulty of breathing goes on for some time increasing ; 
and both inspiration and exspiration are performed slowly, 
and with a wheezing noise. In violent fits, speaking is dif- 
ficult and uneasy. There is often some propensity to 
coughing, but it can hardly be executed. 

1377.] These symptoms often continue for many hours 
together, and particularly from midnight till the morning is 
far advanced. Then commonly a remission takes place by 
degrees; the breathing becomes less laborious and more 
full, so that the person can speak and cough with more 
ease; and, if the cough brings up some mucus, the remis- 
sions becomes immediately more considerable, and the per- 
son falls into a much wished for sleep. 

1378.] During these fits the pulse often continues in its 
natural state ; but in some persons the fits are attended with 
a frequency of pulse, and with some heat and thirst, as 
marks of some degree of fever. If urine be voided at the 
beginning of a fit, it is commonly in considerable quantity, 
and with little color or odor; but, after the fit is over 
the urine voided is in the ordinary quantity, of a high co- 

• This discription of the disease under consideration is excellent 



PRACTICE OF PHYSIC. 429 

lor, and sometime deposits a sediment. In some persons, 
during the fit, the face is a little flushed and turgid ; but 
more commonly it is somewhat pale and shrunk. 

1379.] After some sleep in the morning, the patient, 
for the rest of the day, continues to have more free and 
easy breathing, but it is seldom entirely such. He still 
feels some tightness across his breast, cannot breathe easily 
in a horizontal posture, and can hardly bear any motion 
of his body, without having his breathing rendered more 
difficult and uneasy. In the afternoon he has an unusual 
flatulency of his stomach, and an unusual drowsiness ; and, 
very frequently, these symptoms precede the first attacks 
of the disease. But, whether these symptoms appear or 
not, the difficulty of breathing returns towards the even- 
ing ; and then sometimes gradually increases, till it be- 
comes as violent as in the night before : or if, during the 
day, the difficulty of breathing has been moderate, and the 
person got some sleep in the first part of the night, he is, 
however, waked about midnight, or at sometime between 
midnight and two o'clock in the morning ; and is then sud- 
denly seized with a fit of difficult breathing, which runs 
the same course as the night before. 

1380.] In this manner fits return for several nights suc- 
cessively : but generally, after some nights passed in this 
way, the fits suffer more eonsiderable remissions. This es- 
pecially happens when the remissions are attended with a 
more copious expectoration in the mornings, and that this 
continues from time to time throughout the day. In these 
circumstances, asthmatics, for a long time after, have not 
only more easy days, but enjoy also nights of entire sleep, 
without the recurrence of the disease. 

1381.] When this disease, however, has once taken place 
in the manner above described, it is ready to return at times 
for the whole of life after. These returns, however, hap- 
pen with different circumstances in different persons. 

1382.] In some persons the fits are readily excited by 
external heat, whether of the weather or of a warm cham- 
ber, and particularly by warm bathing. In such persons 
fits are more frequent in summer, and particularly during 
the dog-days, than at other colder seasons. The same per- 
sons are also readily affected by changes of the weather ; 
especially by sudden changes made from a colder to a warm- 
er, or what is commonly the same thing, from a heavier to 
a lighter atmosphere. The same persons are also affected 



430 PRACTICE OF PHYSIC. 

by every circumstance straitening the capacity of the tho- 
rox, as by any ligature made, or even by a plaister laid up- 
on it ; and a like effect happens from any increased bulk of 
the stomach, either by a full meal, or by air collected in it. 
They are likewise much affected by exercise, or whatever 
else can hurry the circulation of the blood. 

1383.] As asthmatic fits seem thus to depend upon some 
fulness of the vessels of the lungs, it is probable than an ob- 
struction of perspiration, and the blood being less determin- 
ed to the surface of the body, may favor an accumulation 
in the lungs, and thereby be a means of exciting asthma. 
This seems to be the case of those asthmatics who have fits 
most frequently in the winter season, and who have com- 
monly more of a catarrhal affection accompanying the asth- 
ma ; which therefore occurs more frequently in winter, and 
more manifestly from the application of cold. 

1384.] Beside these cases of asthma excited by heat or 
cold, there are others, in which the fits are especially excit- 
ed by powers applied to the nervous system ; as by passions 
of the mind, by particular odors, and by irritations of smoke 
and dust. That this disease is an affection of the nervous 
system, and depending upon a mobility of the moving fibres 
of the lungs, appears pretty clearly from its being frequent- 
ly attended with other spasmodic affections depending upon 
mobility ; such as hysteria, hypochondriasis, dyspepsia, and 
atonic gout. 

1385.] From the whole of the history of asthma now de- 
livered, I think it will readily appear, that the proximate 
cause of this disease is a preternatural, and in some measure 
a spasmodic constriction of the muscular fibres of the bron- 
chise ; which not only prevents the dilatation of the bron- 
chia? necessary to a free and full inspiration, but gives also 
a rigidity which prevents a full and free exspiration. . This 
preternatural constriction, like many other convulsive and 
spasmodic affections, is readily excited by a turgescense of 
the blood, or other cause of any unusual fulness and disten- 
tion of the vessels of the lungs. 

1386.] This disease, as coming by fits, may be generally 
distinguished from most other species of dyspnoea, whose 
causes being more constantly applied, produce therefore a 
more constant difficulty of breathing. There may, how- 
ever, be some fallacy in this matter, as some of these causes 
may be liable to have abatements and intensities, whereby 
the dyspnoea produced by them may seem to come by fits ; 



PRACTICE OF PHYSIC. 431 

but I believe it is seldom that such fits put on the appear- 
ance of the genuine asthmatic fits described above. Perhaps, 
however, there is still another case that may give more dif- 
ficulty ; and that is when several of the causes, which we 
have assigned as causes of several of the species of difficult 
breathing referred to the genus of Dyspnoea, may have the 
effect of exciting a genuine asthmatic fit. Whether this can 
happen to any but the peculiarly predisposed to asthma, I 
am uncertain ; and therefore, whether in any such cases, 
the asthma may be considered as symptomatic ; or if, in all 
such cases, the asthma may not still be considered and treat- 
ed as an idiopathic disease. 

1387.] The asthma, though often threatening immediate 
death, seldom occasions it, and many persons have lived 
long under this disease. In many cases, however, it does 
prove fatal ; sometimes very quickly, and perhaps always 
at length. In some young persons it has ended soon, by 
occasioning a phthisis pulmonalis. After a long continu- 
ance, it often ends in a hydrothorax ; and commonly, by 
occasioning some aneurism of the heart or great vessels, it 
thereby proves fatal. 

1388.] As it is seldom that an asthma has been entirely 
cured ; I therefore cannot propose any method of cure 
which experience has approved as generally successful. Bat 
the disease admits of alleviation in several respects from the 
use of remedies ; and my business now shall be chiefly to 
offer some remarks upon the choice and use of the remedies 
which have been commonly employed in cases of asthma. 

1389.] As the danger of an asthmatic fit arises chiefly 
from the difficult transmission of the blood through the ves- 
sels of the lungs, threatening suffocation ; so the most pro- 
bable means of obviating this seems to be blood-letting ; 
and therefore, in all violent fits, practitioners have had re- 
course to this remedy. In first attacks, and especial I y in 
young and plethoric persons, blood-letting may be very- 
necessary, and is commonly allowable. But it is also evi- 
dent, that, under the freq u e n t recurrence of fits, blood-let- 
ting cannot be frequently repeated without exhausting and 
weakening the patient too much. It is further to be observ- 
ed that blood-letting is not so necessary as might be ima- 
gined, as the passage of the blood through the lungs is not 
so much interrupted as has been commonly supposed. This 
I particularly conclude from hence, that, instead of the 
suffusion of face, which is the usual effect of such interrup- 



43S PRACTICE OF PHYSIC. 

tion, the face, in asthmatic fits, is often shrunk and pale. 
I conclude the same also from this, that, in asthmatic fits, 
blood-letting does not commonly give so much relief as, 
upon the contrary supposition, might be expected. 

1390.] As I have aliedged above, that a turgescence of 
the blood is frequently the exciting cause of asthmatic fits, 
so it might be supposed, that a plethoric state of the system 
might have a great share in producing a turgescence of the 
blood in the lungs ; and especially, therefore, that blood- 
Jetting might be a proper remedy in asthma. I allow it to 
be so in the first attacks of the disease : but as the disease, 
by continuing, generally takes oft' the plethoric state of the 
system ; so, after the disease has continued for some time, 
I alledge that blood-letting becomes less and less necessary. 

1391.] Upon the supposition of asthmatics being in a 
plethoric state, purging might be supposed to prove a re- 
medy in this disease : but, both because the supposition is 
not commonly well founded, and because purging is seldom 
found to relieve the vessels of the thorax, this remedy has 
not appeared to be well suited to asthmatics ; and large 
purging has always been found to do much harm. But as 
asthmatics are always hurt by the stagnation and accumula- 
tion of matters in the alimentary canal, so costiveness must 
be avoided, and an open belly proves useful. In the time 
of fits, the employment of emollient and moderately relaxa- 
tive glysters* has been found to give considerable relief. 

1 392.] As a flatulency of the stomach, and other symp- 
toms of indigestion, are frequent attendants of asthma, 
and very troublesome to asthmatics ; so, both for removing 
these symptoms, and for taking off all determination to the 
lungs, the frequent use of gentle vomitsf is proper in this 
disease. In certain cases, where a fit was expected to come 
on in the course of the night, a vomit given in the evening 
has frequently seemed to prevent it. 

J 393.] Blistering between the shoulders, or upon the 
breast, has been frequently employed to relieve asthmatics; 
but in the pure spasmodic asthma we treat of here, I have 
rarely found blisters useful, either in preventing or reliev- 
ing fits. 

1394.] Issues are certainly useful in obviating plethora ; 

* A glyster of milk, with a little salt, is generally sufficient. The costiveness may be removed 
by mucilaginous laxatives of the milder kind, as manna, cassia, &c. or by a proper attention to 
diet, especially by using the pulps of particular fruits, as prunes or raisins boiled in barley-wa- 
ter; roasted apples eaten witli brown sugar, &c. 

+ Vomits ought, in these caiL-, to be mild. Some formulae of them are given in one of the 
notes on article 185. 



PRACTICE OF PHYSIC. 433 

but as such indications seldom arise in cases of asthma, so 
issues have been seldom found useful in this disease. 

1395.J As asthmatic fits are so frequently excited by a 
turgescence of the blood, so the obviating and allaying of 
this by acids and neutral salts, seems to have been at all 
times the object of practitioners. See Floyer on the Asthma. 

1396.] Although a plethoric state of the system may 
seem to dispose to asthma, and the occasional turgescence 
of the blood may seem to be frequently the exciting cause 
of the fits; yet it is evident, that the disease must have 
arisen chiefly from a peculiar constitution in the moving 
fibres of the bronchiae, disposing them upon various occa- 
sions to fall into a spasmodic constriction ; and therefore, 
that the entire cure of the disease can only be expected 
from the correcting of that predisposition, or from correct- 
ing the preternatural mobility or irritability of the lungs in 
that respect. 

1397.] In cases wherein this predisposition depends up- 
on original conformation, the cure must be difficult, and 
perhaps impossible; but it may perhaps be moderated by 
the use of antispasmodics. Upon this footing, various 
remedies of that kind have been commonly employed, and 
particularly the fetid gums ; but we have not found them 
of any considerable efficacy, and have observed them to 
be sometimes hurtful by their heating too much. Some 
other antispasmodics which might be supposed powerful, 
such as musk, have not been properly tried. The vitriolic 
ether has been found to give relief, but its effects are not 
lasting. 

1398. ] As in other spasmodic affections, so in this, the 
most certain and powerful antispasmodic is opium.* I have 
often found it effectual, and generally safe ; and if there 
have arisen doubts with respect to its safety, I believe they 
have arisen from not distinguishing between certain pletho- 
ric and inflammatory cases of dyspnoea, improperly named 
Asthma, and the genuine spasmodic asthma Ave treat 
of here. 

1399.] As in many cases this disease depends upon a 
predisposition which cannot be corrected by our art, so in 
such cases the patient can only escape the disease by avoid- 

* The great efficacy of opium, in cases of spasmodic asthma, is fully confirmed by experience . 
It ought to be given in large doses, but not often repeated in the day. It seems to be most use- 
ful when given occasionally to allay the violence ot the fit, or to prevent us accession. Thus 
lorty drops of laudanum have been frequently found to relieve the symptoms when the fit w 
violent ; or, when laken at the approach of the fit, to have wholly suppressed it, or at least t» 
have considerably blunted its violence. 

3k 



434 PRACTICE OF PHYSIC. 

ing the occasional or exciting causes, which I have endea- 
vored to point out above. It is, however, difficult to give 
anv general rules here, as different asthmatics have their 
different idiosyncrasies with respect to externals. Thus, 
one asthmatic finds himself easiest living in the midst of a 
great city, while another cannot breathe but in the free air 
of the country. In the latter case, however, most asth- 
matics bear the air of a low ground, if tolerable free and 
dry, better than that of the mountain. 

1400.] In diet, also, there is some difference to be made 
with respect to different asthmatics. None of them bear a 
large or full meal, or any food that is of slow and difficult 
solution in the stomach; but many of them bear animal 
food of the lighter kinds, and in moderate quantity. The 
use of vegetables which readily prove flatulent, are always 
very hurtful. In recent asthma, and especially in the young 
and plethoric, a spare, light,- and cool diet is proper, and 
commonly necessary; but after the disease has continued 
for years, asthmatics commonly bear, and even require, 
a tolerable full diet, though in all cases a very full diet is 
very hurtful. 

1401.] In drinking, water, or cool watery liquors, are 
the only safe and fit drinks for asthmatics; and all liquors 
ready to ferment, and become flatulent, are hurtful to 
them. Few asthmatics can bear any kind of strong drink ; 
and any excess in such is always very hurtful to them. As 
asthmatics are commonly hurt by taking warm or tepid 
drink; so, both upon that account and upon account of 
the liquors weakening the nerves of the stomach, neither 
tea nor coffee is proper in this disease. 

1402.] Asthmatics commonly bear no bodily motion ea- 
sily but that of the most gentle kind. Riding, however, 
on horseback, or going in a carriage, and especially sail- 
ing, are very often useful to asthmatics. 



CHAPTER VII. 

OF THE CHINCOUGH, OR HOOPINGCOVGH. 

1403.] HPHIS disease is commonly epidemic, and ma- 

X. nifestly contagious. It seems to proceed 

from a contagion of a specific nature, and of a singular 

quality. It does not, like most other contagions^ necessa- 



PRACTICE OF PHYSIC. 435 

rily produce a fever ; nor doe's it, like most others, occa- 
sion any eruption, or produce otherwise any evident change 
in the state of the human fluids. It has, in common with 
the catarrhal contagion, and with that of the measles, a 
peculiar determination to the lungs ; but with particular 
effects there, very different from those of the other two ; 
as will appear from the history of this disease now to be 
delivered. 

1404.] This contagion, like several others, affects per- 
sons but once in the course of their lives; and therefore, 
necessarily, children are most commonly the subjects of 
this disease: but there are many instances of it occurring 
in persons considerably advanced in life; though it is pro- 
bable, that the further that persons are advanced in life, 
they are the less liable to be affected with this contagion. 

1405.] The disease commonly comes on with the ordi- 
nary symptoms of a catarrh arising from cold ; and often, 
for many days keeps entirely to that appearance; and I 
have had instances of a disease which, though evidently 
arising from the chincough contagion, never put on any 
other form than that of a common catarrh. This, howe- 
ver, seldom happens; for, generally in the second, and at 
farthest in the third week after the attack, the disease puts 
on its peculiar and characteristic symptom, a convulsive 
cough. This is a cough in which the expiratory motions 
peculiar to coughing are made with more frequency, rapi- 
dity, and violence, than usual. As these circumstances, 
however, in different instances of coughing, are in very 
different, degrees; so no exact limits can be put to deter- 
mine when the cough can be strictly said to be convulsive; 
and it is therefore especially by another circumstance that 
the chincough is distinguished from every other form of 
cough. This circumstance is, when many expiratory 
motions have been convulsively made, and thereby the air 
is in great quantity thrown out from the lungs, a full in- 
spiration is necessarily and suddenly made; which, by 
the air rushing in through the glottis with unusual veloci- 
ty, gives a peculiar sound. This sound is somewhat dif- 
ferent in different cases, but is in general called a Hoop; 
and from it the whole of the disease is called the Hooping 
Cough. When this sonorous inspiration has happened, the 
convulsive coughing is again renewed, and continues in 
the same manner as before, till a quantity of mucus is 
thrown up from the lungs, or the contents of the stomach 

• 



436 PRACTICE OF PHYSIC. 

are thrown up by vomiting. Either of these evacuations 
commonly puts an end to the coughing, and the patient re- 
mainsfree from it for some time after. Sometimes it is on- 
ly after several alternate fits of coughing and hooping that 
expectoration or vomiting takes place; but it is commonly 
after the second coughing that these happen, and put an 
end to the fit. 

1406.1 When the disease, in this manner, has taken its 
proper form, it generally continues for a long time after, 
and generally from one month to three ; but sometimes 
much longer, and that with very various circumstances. 

1407.] The fits of coughing return at various intervals, 
rarely observing any exact period. They happen frequent- 
ly in the course of the day, and more frequently still in the 
course of the night. The patient has commonly some 
warning of their coming on ; and, to avoid that violent and 
painful concussion which the coughing gives to the whole 
body, he clings fast to any thing that is near to him, or de- 
mands to be held fast by any person that he can come at. 

When the fit is over, the patient sometimes breathes fast, 
and seems fatigued for a little after : but in many this ap- 
pears very little ; and children are commonly so entirely 
relieved, that they immediately return to their play, or what 
else they were occupied in before. 

1408.] If it happens that the fit of coughing ends in vo- 
miting up the contents of the stomach, the patient is com- 
monly immediately after seized with a strong craving and 
demand for food, and takes it in very greedily. 

1409.] At the first coming on of this disease, the expec- 
toration is sometimes none at all, or of a thin mucus only ; 
and while this continues to be the case, the fits of coughing 
are more violent, and continue longer ; but commonly the 
expectoration soon becomes considerable, and a very thick 
mucus, often in great quantity, is thrown up ; and as this 
is more readily brought up, the fits of coughing are of 
shorter duration, 

1410.] The violent fits of coughing frequently 'interrupt 
the free transmission of the blood through the lungs, and 
thereby the free return of blood from the vessels of the head. 
This occasions that turgescence and suffusion of face which 
commonly attends the tits of coughing, and seems to occa- 
sion also those eruptions of blood from the nose, and even 
from the eyes and ears, which sometimes happen in this 
disease. 



PRACTICE OF PHYSIC. 437 

1411.] This disease often takes place in the manner we 
have now described, without any pyrexia attending it ; but, 
though Sydenham had seldom observed it, we have found 
the disease very frequently accompanied with pyrexia, 
sometimes from the very beginning, but more frequently 
only after the disease had continued for some time. When 
it does accompany the disease, we have not found it appear- 
ing under any regular intermittent form. It is constantly 
in some degree present ; but with evident exacerbations to- 
wards evening, continuing till next morning. 

1412.] Another symptom very frequently attending the 
chincough, is a difficulty of breathing ; and that not only 
immediately before and after fits of coughing, but as con- 
stantly present, though in different degrees in different per- 
sons. I have hardly ever seen an instance of a fatal chin- 
cough, in which a considerable degree of pyrexia and 
dyspnoea had not been for some time constantly present. 

1413.] When by the power of the contagion this disease 
has once taken place, the fits of coughing are often repeat- 
ed, without any evident exciting cause: but in many cases, 
the contagion may be considered as giving a predisposition 
only ; and the frequency of fits depends in some measure 
upon various exciting causes ; such as, violent exercise ; a 
full meal ; the having taken in food of difficult solution ; 
irritation of the lungs by dust, smoke or disagreeable 
odors of a strong kind : and especially any considerable 
emotion of the mind. 

1414.] Such are the chief circumstances of this disease, 
and it is of various event ; which, however, may be common- 
ly foreseen by attending to the following considerations. 

The younger that children are, they are in the greater 
danger from this disease ; and of those to whom it proves 
fatal, there are many more under two years old than above it. 
The older that children are, they are the more secure 
against an unhappy event ; and this I hold to be a very ge- 
neral rule, though I own there are many exceptions to it. 

Children born of phthisical and asthmatic parents are in 
the greatest danger from this disease. 

When the disease beginning in the form of a catarrh, is 
attended with fever and difficult breathing, and with little 
expectoration, it often proves fatal, without taking on the 
form of the hoopingcough ; but, in most of such cases, the 
coming on of the convulsive cough and hooping, bringing 



438 PRACTICE OF PHYSIC. 

on at the same time a more free expectoration, generally 
removes the danger. 

When the disease is fully formed, if the fits are neither 
frequent nor violent, with moderate expectoration, and the 
patient, during the intervals of the fits, is easy, keeps his 
appetite, gets sleep, and is without fever or difficult breath- 
ing, the disease is attended with no danger ; and these cir- 
cumstances becoming daily more favorable, the disease ve- 
ry soon spontaneously terminates. 

An expectoration, either very scanty or very copious, is 
attended with danger ; especially if the latter circumstance 
is attended with great difficulty of breathing. 

Those cases in which the fits terminate by a vomiting, 
and are immediately followed by a craving of food, are ge- 
nerally without danger. 

A moderate hemorrhagy from the nose often proves salu- 
tary ; but very large hemorrhagies are generally very hurtful. 

This disease coming upon persons under a state of much 
debility, has very generally an unhappy event. 

The danger of this disease sometimes arises from the vio- 
lence of the fits of coughing, occasioning apoplexy, epilep- 
sy, or immediate suffocation : but these accidents are very 
rare : and the danger of the disease seems generally to be in 
proportion to the fever and dyspncea attending it. 

1415.] The cure of this disease has been always consi- 
dered as difficult, whether the purpose be to obviate its fa- 
tal tendency when it is violent, or merely to shorten the 
course of it when it is mild. When the contagion is recent, 
and continues to act, we neither know how to correct, nor 
how to expel it ; and therefore the disease necessarily con- 
tinues for some time : but it is probable, that the contagion 
in this as in other instances ceases at length to act ; and that 
then the disease continues, as in other convulsive affections, 
by the power of habit alone. 

1416.] From this view of the matter I maintain, that the 
practice must be different, and adapted to two different in- 
dications, according to the period of the disease. At the 
beginning of the disease, and for some time after, the rem^. 
dies to be employed must be such as may obviate the violent 
effects of the disease, and the fatal tendency of it ; but, after 
the disease has continued for some time, and is without anv 
violent symptoms, the only remedies which can be required 
are those which may interrupt its course, and put an entire 
stop to it sooner than it would have spontaneously ceased. 



PRACTICE OF PHYSIC. 439 



1417.] For answering the first indication. In plethoric 
subjects, or in others, when from the circumstances of the 
cough and fits it appears that the blood is difficultly trans- 
mitted through the lungs, blood-letting* is a necessary reme- 
dy ; and it may be even necessary to repeat it, especially in 
the beginning of the disease ; but, as spasmodic affections 
do not commonly admit of much bleeding, so it is seldom 
proper in the chincough to repeat this remedy often. 

1418.] As costiveness frequently attends this disease, so 
it is necessary to obviate or remove it by laxatives employ- 
ed ; and keeping an open belly is generally useful : but 
large evacuations in this way are commonly hurtful. f 

1419.] To obviate or remove the inflammatory determi- 
nation to the lungs that sometimes occurs in this disease, 
blistering is often useful, and even repeated blistering has 
been of service ; but issues have not so much effect, and 
should by no means supersede the repeated blistering that 
may be indicated. When blisters are proper, they are 
more effectual when applied to the thorax, than when ap- 
plied to any distant parts. 

1420.] Of all other remedies, emetics are the most useful 
in this disease ; both in general by interrupting the return 
of spasmodic affections, and in particular by determining 
very powerfully to the surface of the body, and thereby 
taking off determinations to the lungs. For these purposes, 
I think, full vomiting is frequently to be employed ; and, 
in the intervals necessary to be left between the times Of full 
vomiting, nauseating doses of the antimonial emetics may 
be useful. J I have never found the sulphur auraium, so 
much praised by Clossius, to be a convenient medicine, on 
account of the uncertainty of its dose ; and the tartar 
emetic employed in the manner directed by the late Dr. 
Fothergill, has appeared to be more useful. 

142 1 .] These are the remedies to be employed in the first 

* Bleeding, in these cases, is best performed by leeches ; and they seem to give greater relief 
when applied about the neck than on any other part. 

+ In general, the belly may be kept open by a proper attention to diet : roasted apples, eaten 

with brown sugar, stewed prunes, and other similar food, which children generally devour with 

sufficiently answer the purpose of removing or preventing costiveness. 

t The method ol giving tartar-emetic in nauseating doses has been frequently mentioned in 

preceding notes; but in cases of chincough, where children are generally our patients, we are 

umler the necessity of varying the doses to the age and constitution. When the cluM is under 

■ light to use the weak solution of tartar-emetic, specified in the end of the last 

d doses of a table-spoonful every ten or fifteen minutes, till itope- 

to young children, are frequently attended with dangerous con- 

(.•following case is sufficient prmjt — To a child of ten months old, ilut 

hall a grain ol tartar-emetic was given in a little cinnamon water. 

:iig was produced, and the child died suddenly, during the action of the medi- 

bod) altci dtaih, we found the stomach burit, llieie being in it a lace- 

uieil two lingers. The inspection of this body has made uic always curuudr 

cautious in administering emetics to young children. 



440 PRACTICE OF PHYSIC. 

stage of the disease for obviating its fatal tendency, and 
putting it into a safe train. But in the second stage, when 
I suppose the contagion has ceased to act, and that the dis- 
ease continues merely by the power of habit, a different in- 
dication arises, and different remedies are to be employed. 

1422.] This disease, which often continues for a long 
time, does not, in my opinion, continue during the whole 
of that time in consequence of the contagion's remaining in 
the body, and continuing to act in it. That the disease does 
often continue long after the contagion has ceased to act, and 
that too by the power of habit alone, appears to me proba- 
ble from hence, that terror has frequently cured the disease ; 
that any considerable change in the state of the system, such 
as the coming on of the small-pox, has also cured it ; and 
lastly, that it has been cured by antispasmodic and tonic 
medicines ; whilst none of all these means of cure can be 
supposed either to correct or to expel a morbific matter, 
though they are evidently suited to change the state and ha- 
bits of the nervous system. 

1423.] From this view we are directed to the indication 
that may be formed, and in a great measure to the remedies 
which may be employed in what we suppose to be the se- 
cond stage of the disease. It ma}' perhaps be alledged, that 
this indication of shortening the course of the disease is not 
very important or necessary, as it supposes that the danger 
or violence is over, and in consequence, that the disease 
will soon spontaneously cease. The last supposition, how- 
ever, is not well founded ; as the disease, like many other 
convulsive and spasmodic affections, may continue for a 
long time by the power of habit alone, and by the repetition 
of paroxysms may have hurtful effects ; more especially as 
the violence of paroxysms, and therefore their hurtful effects, 
may be much aggravated by various external causes that 
may be accidentally applied. Our indication, therefore, is 
proper ; and we proceed to consider the several remedies 
which may be employed to answer it. 

1424.] Terror may possibly be a powerful remedy, but 
it is difficult to measure the degree of it that shall be pro- 
duced ; and, as a slight degree of it may be ineffectual, and 
a high degree of it dangerous, I cannot propose to employ it. 

1425.] The other remedies which' we suppose suited to 
our second indication, and which indeed have been frequent- 
ly employed in this disease, are antispasmodics or tonics. 

Of the antispasmodics, castor has been particularly re- 



PRACTICE OF PHYSIC. 441 

commended by Dr. Morris ; but in many trials we have not 
found it effectual. 

With more probability musk has been employed : but 
whether it be from our not having it of a genuine kind, or 
not employing it in sufficiently large doses, I cannot deter- 
mine ; but we have not found it commonly successful. Of 
antispasmodics, the most certainly powerful is opium : and 
when there is no considerable fever or difficulty of breathing 
present, opium has often proved useful in moderating the 
violence of the chincough ; but I have not known it employ- 
ed so as entirely to cure disease. 

If hemlock has proved a remedy in this disease, as we 
must believe from Dr. Butter's accounts, I agree with that 
author, that it is to be considered as an antispasmodic. 
Upon this supposition, it is a probable remedy ; and from 
the accounts of Dr. Butter and some others, it seems to have 
been often useful : but, in our trials, it has often disap- 
pointed us, perhaps from the preparation of it not having 
been always proper.* 

1426.] Of the tonics, I consider the cupmoss, formerly 
celebrated, as of this kind ; as also the bark of the misle- 
toe ; but I have had no experience of either, as I have al- 
ways trusted to the Peruvian bark. I consider the use of 
this medicine as the most certain means of curing the disease 
m its second stage ; and when there has been little fever pre- 
sent, and a sufficient quantity of the bark has been given, it 
has seldom failed of soon putting an end to the disease. 

1427.] When convulsive disorders maybe supposed to 
continue by the force of habit alone, it has been found that 
a considerable change in the whole of the circumstances 
and manner of life has proved a cure of such diseases; and 
analogy has applied this in the case of the chincough so far, 
that a change of air has been employed, and supposed to be 
useful. In several instances I have observed it to be so ; 
but I have never found the effects of it durable, or suffi- 
cient to put an entire stop to the disease. 

• Experience has not found that any of the antispasmodics have erer been employed with 
much advantage in this disease. All of them are extremely nauseous, and contequAiilj d)t). - 
lAilttjr giten to children who cannot well swallow pillt. 



Sl 



442 PRACTICE OF PHYSIC. 



SECTION III. 



Of the Spasmodic Affections in the Natural 
Functions. 

CHAPTER VIII. 

OF THE PYROSIS, OR WHAT IS NAMED IN 
SCOTLAND, THE WATER-BRASH. 

1428.] r T , HE painful sensations referred to the stomach, 
A and which are probably occasioned by real 
affections of this organ, are of different kinds. Probably 
they proceed from affections of different natures, and should 
therefore be distinguished by different appellations ; but I 
must own that the utmost precision in this matter will be 
difficult. In my essay towards a methodical Nosology, I 
have, however, attempted it. For those pains that are 
either acute and pungent, or accompanied with a sense of 
distention, or with a sense of constriction, if they are at 
the same time, not attended with any sense of acrimony 
or heat, I employ the appellation of Gastrodynia. To ex- 
press those painful or uneasy sensations which seem to arise 
from a sense of acrimony irritating the part, or from such a 
sense of heat as the application of acrids, whether externally 
or internally applied, often gives, I employ the term of 
Cardialgia ; and by this I particularly mean to denote those 
feelings which are expressed by the term Heartburn in the 
English language. I think the term Soda has been com- 
monly employed by practical writers to express an affection 
attended with feelings of the latter kind. 

1429.] Beside the pains denoted by the terms Gastrody- 
nia, Periadynia, Cardialgia, and Soda, there is, 1 think 
another painful sensation different from all of these, which 
is named by Mr. Sauvages, Pyrosis Suecica; and his ac- 
count of it is taken from Linnaeus, who names it Cardialgia 
Sputatoria. Under the title of Pyrosis Mr. Sauvages has 
formed a genus, of which the whole of the species, except 
the eighth, which he gives under the title of Pyrosis Sue- 
cica, are all of them species of the Gastrodynia or of the 
Cardialgia; and if there is a genus to be formed under the 
title of Pyrosis, it can in my opinion comprehend only 
the species I have mentioned. In this case, indeed, I own 



PRACTICE OF PHYSIC. 443 

that the term is not very proper; but my aversion to intro- 
duce new names has made me continue to employ the 
term of Mr. Sauvages. 

1430.] The Gastrodynia and Cardialgia I judge to be 
for the most part symptomatic affections; and therefore 
have given them no place in this work: but the Pyrosis, 
as an idiopathic disease, and never before treated of in any 
system, I propose to treat of here. 

1431.] It is a disease frequent among people in lower 
life; but occurs also, though more rarely, in people of bet- 
ter condition. Though frequent in Scotland, it is by no 
means so frequent as Linnaeus reports it to be in Lapland. 
It appears most commonly in persons under middle age, 
but seldom in any persons before the age of puberty. 
When it has once taken place, it is ready to recur occasion- 
ally for a long time after; but it seldom appears in persons 
considerably advanced in life. It affects both sexes, but 
more frequently the female. It sometimes attacks preg- 
nant women, and some women only when they are in that 
condition. Of other women, it more frequently affects 
the unmarried; and of the married, most frequently the 
barren. I have had many instances of its occurring in wo- 
men laboring under a fluor albus. 

1432.] The fits of this disease usually come on in the 
morning and forenoon, when the stomach is empty. The 
first symptom of it is a pain at the pit of the stomach, with 
a sense of constriction, as if the stomach was drawn towards 
the back ; the pain is increased by raising the body into an 
erect posture, and therefore the body is bended forward. 
This pain is often very severe; and, after continuing for 
sometime, it brings on an eructation of a thin watery fluid 
in considerable quantity. This fluid has sometimes an 
acrid taste, but is very often absolutely insipid. The eruc- 
tation is for some time frequently repeated ; and docs not 
immediately give relief to the pain which preceded it, but 
does so at length, and puts an end to the fit. 

1433.] The fits of this disease commonly come on with- 
out any evident exciting cause: and I have not found it 
steadily connected with any particular diet. It attacks per- 
sons using animal food, but I think more frequently those 
living on milk and farinacea. It seems often to be excited 
by cold applied to the lower extremities; and is readily 
excited by any considerable emotion of mind. It is often 
lyithout any symptoms of dyspepsia. 



444 PRACTICE OF PHYSIC. 

1434.] The nature of this affection is not rery obvious; 
but I think it may be explained in this manner: It seems 
to begin by a spasm of the muscular fibres of the stomach ; 
which is afterwards, in a certain manner, communicated to 
the blood-vessels and exhalants, so as to increase the impe- 
tus of the fluids in these vessels, while a constriction takes 
place on their extremities. While therefore the increased 
impetus determines a greater quantity than usual of fluids 
into these vessels, the constriction upon their extremities 
allows only the pure watery parts to be poured out, ana- 
logous, as I judge, in every respect, to what happens in 
the diabetes hystericus. 

1435.] The practice in this disease is as difficult as the 
theory. The paroxysm is only to be certainly relieved by 
opium. Other antispasmodics, as vitriolic ether and vola- 
tile alkali, are sometimes of service, but not constantly so. 
Although opium and other antispasmodics relieve the fits, 
they have no effect in preventing their recurrence. For 
this purpose, the whole of the remedies of dyspepsia have 
been employed without success. Of the use of the nux 
vomica, mentioned as a remedy by Linnaeus, I have had 
no experience. 



CHAPTER IX. 
OF THE COLIC. 

1436.] r I "'HE principal symptom of this disease, is a 
X pain felt in the lower belly. It is seldom 
fixed and pungent in one part, but is a painful distention 
in some measure spreading over the whole of the belly; 
and particularly with a sense of twisting or wringing round 
the navel. At the same time, with this pain, the navel 
and teguments of the belly are frequently drawn inwards, 
and often the muscles of the belly are spasmodically con- 
tracted, and this in separate portions, giving the appear- 
ance of a bag full of round balls. 

1437.] Such pains, in a certain degree, sometimes occur 
in cases of diarrhoea and cholera; but these are less violent 
and more transitory, and are named Gripings. It is onlr 
when more violent and permanent, and attended with cos- 
tiveness, that they constitute colic. This is also common! v 
attended with vomiting, which in many cases is frequently 



PRACTICE OF PHYSIC. 445 

repeated, especially when any thing is taken down into the 
stomach; and in such vomitings, not only the contents of 
the stomach are thrown up, but also the contents of the du- 
odenum, and therefore frequently a quantity of bile. 

1438.] In some cases of colic, the peristaltic motion is 
inverted through the whole length of the alimentary canal, 
in such a manner that the contents of the great guts, and 
therefore, stercoraceous matter, is thrown up by vomiting ; 
and the same inversion appears still more clearly from this, 
that what is thrown into the rectum by glyster is again 
thrown out by the mouth. In these circumstances of inver- 
sion the disease has been named Ileus, or the Iliac Passion ; 
and this has been supposed to be a peculiar disease distinct 
from colic ; but to me it appears that the two diseases are 
owing to the same proximate cause, and have the same 
symptoms, only in a different degree. 

1439.] The colic is often without any pyrexia attending 
it. Sometimes, however, an inflammation comes upon the 
part of the intestine especially affected ; and this inflamma- 
tion aggravates all the symptoms of the disease, being pro- 
bably what brings on the most considerable inversion of the 
peristaltic motion; and, as the stercoraceous vomiting is 
what especially distinguishes the ileus, this has been consi- 
dered as always depending on an inflammation of the in- 
testines. However, I can affirm, that as there are inflam- 
mations of the intestines without stercoraceous vomiting, 
so I have seen instances of stercoraceous vomiting without 
inflammation; and there is therefore no ground for distin- 
guishing ileus from colic, but as a higher degree of the 
same affection. 

1440.] The symptoms of the colic, and the dissections 
of bodies dead of this disease, show very clearly that it de- 
pends upon a spasmodic constriction of a part of the intes- 
tines ; and that this therefore is to be considered as the proxi- 
mate cause of the disease. In some of the dissections of 
persons dead of this disease, an intus-susception has been 
remarked to have happened ; but whether this be constantly 
the case in all the appearances of ileus, is not certainly de- 
termined. 

1441.] The colic has commonly been considered as being 
of different species, but I cannot follow the writers on this 
subject in the distinctions they have established. So far, 
however, as a difference of the remote cause constitutes a 
difference of species, a distinction may perhaps be admit- 



446 PRACTICE OF PHYSIC. 

ted ; and accordingly in my Nosology I have marked seven 
different species : but I am well persuaded, that in all these 
different species the proximate cause is the same, that is, a 
spasmodic constriction of a part of the intestines : and con- 
sequently, that in all these cases the indication of cure is 
the same, that is, to remove the constriction mentioned. 
Even in the several species named Stercorea, Callosa, and 
Calculosa, in which the disease depends upon an obstruction 
of the intestine, I am persuaded that these obstructions do 
not produce the symptoms of colic, excepting in so far as 
they produce spasmodic constrictions of the intestines ; and 
therefore, that the means of cure in these cases, so far as they 
admit of cure, must be obtained by the means which the 
general indication above-mentioned suggests. 

1442.] The cure, then, of the colic universally, is to be 
obtained by removing the spasmodic constrictions of the 
intestines ; and the remedies suited to this purpose may be 
referred to three general heads : 

1. The taking off the spasm by various antispasmodic 
powers. 

2. The exciting the action of the intestines by purgatives. 

3. The employing mechanical dilatation. 

1443.] Before entering upon a particular account of 
these remedies, it will be proper to observe, that in all cases 
of violent colic, it is advisable to practise blood-letting ; both 
as it may be useful in obviating the inflammation which is 
commonly to be apprehended, and even as it may be a means 
of relaxing the spasm of the intestine. This remedy may 
perhaps be improper in persons of a weak and lax habit, 
but in all persons of tolerable vigor it will be a safe remedy ; 
and in all cases where there is the least suspicion of an in- 
flammation actually coming on, it will be absolutely neces- 
sary. Nay, it will be even proper to repeat it perhaps se- 
veral times, if, with a full and hard pulse, the appearance of 
the blood drawn, and the relief obtained by the first bleed- 
ing, shall authorise such repetition. 

1444.] The antispasmodic powers that may be employed, 
are, the application of heat in a dry or humid form, the 
application of blisters, the use of opium, and the use of mild 
oils. 

The application of heat, in a dry form, has been employ- 
ed by applying to the belly of the patient a living animal, 
or bladders filled with warm water, or bags of substances 
which long retain their heat ; and all these have sometimes 



PRACTICE OF PHYSIC. 4tf 

been applied with success ; but none of them seem to me 
so powerful as the application of heat in a humid form. 

This may be employed either by the immersion of a 
great part of the body in warm water, or by fomenting the 
belly with cloths wrung out of hot water. The immersion 
has advantages from the application of it to a greater part 
of the body, and particularly to the lower extremities : but 
immersion cannot always be conveniently practised, and fo- 
mentation may have the advantage of being longer conti- 
nued ; and it may have nearly all the benefit of immersion, 
if it be at the same time applied both to the belly and to 
the lower extremities. 

1445.] From considering that the teguments of the low- 
er belly have such a connection with the intestines, as at 
the same time to be affected with spasmodic contraction, 
we perceive that blisters applied to the belly may have the 
effect of taking off the spasms both from the muscles of 
the belly and from the intestines ; and accordingly, blis- 
tering has often been employed in the colic with advan- 
tage. Analogous to this, rubefacients applied to the belly 
have been frequently found useful. 

1446.] The use of opium in the colic may seem to be 
an ambiguous remedy. Very certainly it may for some 
time relieve the pain, which is often so violent and urgent, 
that it is difficult to abstain from the use of such a remedy. 
At the same time, the use of opium retards or suspends 
the peristaltic motion so much, as to allow the intestines to 
fall into constrictions ; and may therefore, while it relieves 
the pain, render the cause of the disease more obstinate. 
On this account, and further as opium prevents the opera- 
tion of purgatives so often necessary in this disease, many 
practitioners are averse to the use of it, and some entirely 
reject the use of it as hurtful. There are, however, others 
who think they can employ opium in this disease with much 
advantage. 

In all cases where the colic comes on without any pre- 
vious costiveness, and arises from cold, from passions of the 
mind, or other causes which operate especially on the ner- 
vous system, opium proves a safe and certain remedy ; but 
in cases which have been preceded by long costiveness, or 
where the colic, though not preceded by costiveness, has 
however continued for some days without a stool, so that 
a stagnation of faeces in the colon is to be suspected, the use 
of opium is of doubtful effect. In such cases, unless a 



448 PRACTICE OF PHYSIC. 

stool has been first procured by medicine, opium cannot 
be employed but with some hazard of aggravating the dis- 
ease. However, even in those circumstances or costive- 
ness, when, without inflammation, the violence of the 
spasm is to be suspected, when vomiting prevents the ex- 
hibition of purgatives, and when with all this the pain is 
extremely urgent, opium is to be employed, not only as 
an anodyne, but also as an antispasmodic, necessary to fa- 
vor the operation of purgatives ; and may be so employed, 
when, either at the same time with the opiate, or not long 
after it, a purgative can be exhibited. 

Is the hyoscyamus, as often showing, along with its 
narcotic, a purgative quality, better suited to this disease 
than opium ? 

1447.] It is seemingly on good grounds that several 
practitioners have recommended the Targe use of mild oils 
in this disease, both as antispasmodics and as laxatives ; 
and, where the palate and stomach could admit them, I 
have found them very useful. But as there are few Scot- 
tish stomachs that can admit a large use of oils, I have had 
few opportunities of employing them. 

1448.] The second set of remedies adapted to the cure 
of colic, are purgatives ; which, by exciting the action of 
the intestines, either above or below the obstructed place, 
may remove the constriction ; and therefore these purga- 
tives may be given either by the mouth, or thrown bv gly- 
ters into the anus. As the disease is often seated in the 
great guts ; as glysters, by having a more sudden opera- 
tion, may give more immediate relief; and as purgatives 
given by the mouth are ready to be rejected by vomiting ; 
so it is common, and indeed proper, to attempt curing the 
colic in the first place by glysters. These may at first be 
of the mildest kind, consisting of a large bulk of water, 
with some quantity of mild oil ; and such are sometimes 
sufficiently efficacious : however, they are not always so j 
and it is commonly necessary to render them more power- 
fully stimulant by the addition of neutral salts, of which 
the most powerful is the common or marine salt. If these 
saline glysters, as sometimes happens, are rendered again 
too quickly, and on this or otherwise are found ineffec- 
tual, it may be proper instead of these salts, to add to 
the glysters an infusion of senna, or of some other purga- 
tive that can be extracted by water. The antimonial wine.* 

•Tartar emetic is surer than the antimonial wine ; but it is a very violent remedy, and ought 
to> be used wiih caution even in ;lytte«. Five or u* grains k the usual quantity given in glysiers- 



PRACTICE OF PHYSIC. 449 

may be sometimes employed in glysters with advantage. 
Hardly any glysters are more effectual than those made 
of turpentine properly* prepared. When all other injec- 
tions are found ineffectual, recourse is to be had to the in- 
jection of tobacco smoke ; and, when even this fails, recourse 
is to be had to the mechanical dilatation to be mentioned 
hereafter. 

1449.] As glysters often fail altogether in relieving this 
disease, and as even when they give some relief they are 
often imperfect in producing a complete cure ; so it is ge- 
nerally proper, and often necessary, to attempt a more en- 
tire and certain cure by purgatives given by the mouth. 
The more powerful of these, or, as they are called, the 
Drastic Purgatives, may be sometimes necessary; but their 
use is to be avoided, both because they are apt to be reject- 
ed by vomiting, and because when they do not succeed in 
removing the obstruction, they are ready to induce an in- 
flammation. Upon this account it is usual, and indeed pro- 
{>er, at least in the first place, to employ the milder and 
ess inflammatory purgatives. None have succeeded with 
me better than the chrystals of tartar, f because this medi- 
cine may be given in small but repeated doses to a conside- 
rable quantity ; and under this management it is the purga- 
tive least ready to be rejected by vomiting, and much less 
so than the other neutral salts. If a stronger purgative be 
required, jalap, % properly prepared, is less offensive to 
the palate, and sits better upon the stomach, than most 

* The proper manner of preparing turpentine glysters is as follows : 

R. Tereb. Venet. 3vi. 
Vitel. Ov. No. ii. 

Tere in raortario marmoreo donee penitus solvetur Terebinthina j dein adde gradatim, 

Aq. font, frigida, 5ii. 

Huic aflunde 

Aq. font, tepid, lb. i. 

M. f. Enema, statim injiciend. 

the turpentine does not dissolve sufficiently with the yolks of two eggs, a third may be added. 

+ Crystals of tartar may be given in doses of two drachms each, repeated every two hours or 
oftener. The chief objection against the use of this salt is its difficult solution in water, and 
therefore many practitioners prefer the soluble tartar, or the Rochel salt. 

t The Pulvis Jalap, comp. of the Edinburgh Pharmacopoeia answers in general very well ; but 
the following formula is less liable to be rejected by the vomiting which s» frequently accom- 
panies this disease. 

R. Resin. Jalap, gr. xii. 

Amygdal. dulc. decorticat. No. vi. 
Sacch. alb. 3>- 

Tere in raortario marmoreo, et adde gradatim, 

Aq. Cinnamom. simpl. B>« 
M. f. haust. 

Half of this portion may be given at once, and the otber half an bour afterward. 

3m 



450 PRACTICE OF PHYSIC. 

other powerful purgatives. On many occasions of colic, 
nothing is more effectually purgative than a large dose of 
calomel.* Some practitioners have attempted to remove 
the obstruction of the intestines by antimonial emeticsf 
exhibited in small doses, repeated at proper intervals ; and 
when these doses are not entirely rejected by vomiting, 
they often prove effectual purgatives. 

When every purgative has failed, the action of the in- 
testines has been effectually excited by throwing cold wa- 
ter on the lower extremities. 

1450.] The third means of overcoming the spasm of the 
intestines in this disease, is by employing a mechanical di- 
latation ; and it has been frequently supposed that quick- 
silver, given in large quantity, might operate in this man- 
ner. I have not, however, found it successful ; and the 
theory of it is with me very doubtful. Some authors have 
mentioned the use of gold and silver pills, or balls, swal- 
lowed down ; but I have no experience of such practices, 
and I cannot suppose them a probable means of relief. 

1451.] Another means of mechanical dilatation and a 
more probable measure, is by injecting a large quantity of 
warm water by a proper syringe, which may throw it with 
some force, and in a continued stream, into the rectum. 
Both from the experiments reported by the late Mr. De 
Haen, and from those I myself have had occasion to make, 
I judge this remedy to be one of the most powerful and 
effectual.^ 

1452.] I have now mentioned all the several means that 
may be employed for the cure of the colic, considered as 
a genus ; but before I quit this subject, it may be expected 
that I should take notice of some of the species which may 
seem to require a particular consideration. In this view 
it may be expected that I should especially take notice of 
that species named the Colic of Poitou, and particularly 
known in England by the name of the Devonshire Colic. 

1453.] This species of the disease is certainly a peculiar 
one, both in respect of its cause and its effects ; but, as to 
die first, it has been lately so much the subject of investi- 

* This is French practice, but it is dangerous. It has however been serviceable in many cases, 
when given in closes of 12"or 15 grains, oreven a scrup!« when other purgatives have failed. 

+ As the stomach, as was before observed, is very irritable in this disease, the practitioner will 
find considerable difficulty in managing antimonials. It is better to avoid them altogether, for 
they may do much mischief. 

t It is to be thrown up,. by means of a large syringe, in such quantities, that the patient be- 
gins to feel a sense of uneasiness from the great di>tenlion which it occasions. Some patient 
have borne two gallons to be injected, and the cases were attended with the desired success 

The cases in which these large injections are most useful, are those in which hardened faecee 
are accumulated in the colon. The warm water answers two intentions, viz. dilating the pis 
sige, andsoltening the feces, 



PRACTICE OF PHYSIC. 451 

•gation, and is so well ascertained by the learned physicians 
Sir George Baker and Dr. Hardy, that it is unnecessary 
for me to say any thing of it here. 

With respect to the cure of it,* so far as it appears in 
the form of a colic, my want of experience concerning it 
does not allow me to speak with any confidence on the sub- 
ject ; but, so far as 1 can learn from others, it appears to 
me, that it is to be treated by all the several means that I 
have proposed above for the cure of colic in general. 

How far the peculiar effects of this disease are to be cer- 
tainly foreseen and obviated, 1 have not properly learned ; 
end 1 must leave the matter to be determined by those who 
have had sufficient experience in it. 



CHAPTER X. 
OF THE CHOLERA. 

1454.] TN this disease, a vomiting and purging concur- 

-L ring together, or frequently alternating with 

one another, are the chief symptoms. The matter rejected 

both upwards and downwards appears manifestly to consist 

chiefly of bile. 

1455.] From this last circumstance I conclude, that the 
disease depends upon an increased secretion of bile, and its 
copious effusion into the alimentary canal : and, as in this 
it irritates and excites the motions above mentioned, I infer, 
that the bile thus effused in larger quantity is at the same 
time also of a more acrid quality. This appears likewise 
from the violent and very painful gripings that attend the 
disease, and which we can impute only to the violent spas- 
modic contractions of the intestines that take place here. 
These spasms are commonly communicated to the abdomi- 
nal muscles, and very frequently to those of the extremities. 

1456.] In the manner now described, the disease frequent- 
ly proceeds with great violence, till the strength of the pa- 
tient is greatly, and often suddenly, weakened ; while a cold- 
ness of the extremities, cold sweats, and faintings, coming 

• In the early stages of this disease, the belly is to be kept open by the mildests laxatives, and 
a milk diet smelly used. The following formula answers extremely well. 

R. Mannat, 

01. Olivar. aa Si. 
M. f. Linctus. 

Tins quantity is a proper dose, and it may be repeated every day with thirty or forty drop, of 
laudanum at bed-time. If the lymuiucu, Uowever, do n»t abate, we m«y at the same lime 
give large emollient glyttcn. 



452 PRACTICE OF PHYSIC. 

on, an end is put to the patient's life, sometimes in the course 
of one day. In other cases the disease is less violent, con- 
tinues for a day or two, and then ceases by degrees ; though 
such recoveries seldom happen without the assistance of 
remedies. 

1457.] The attacks of this disease are seldom accompa- 
nied with any symptoms of pyrexia ; and though, during 
the course of it, both the pulse and respiration are hurried 
and irregular, yet these symptoms are generally so entirely 
removed by the remedies that quiet the spasmodic affection 
peculiar to the disease, as to leave no ground for supposing 
that it had been accompanied by any proper pyrexia. 

1458.] This is a disease attending a very warm state of 
the air; and, in very warm climates, it may perhaps appear 
at any time of the year : but even in such climates it is most 
frequent during their warmest seasons; and in temperate 
climates, it appears only in the warm seasons. Dr. Syden- 
ham considered the appearances of this disease in England 
to be confined to the month of August; but he himself ob- 
served it to appear sometimes towards the end of summer, 
when the season was unusually warm ; and that, in propor- 
tion to the heat, the violence of the disease was greater. 
Others have observed that it appeared more early in sum- 
mer, and always sooner or later, according as the great 
heats sooner or later set in. 

1459.] From all these circumstances, it is, I think, very 
evident, that this disease is the effect of a warm atmosphere, 
producing some change in the state of the bile in the human 
body : and the change may consist, either in the matter of 
the bile being rendered more acrid, and thereby fitted to ex- 
cite a more copious secretion ; or, in the same matter, its 
being prepared to pass off in larger quantity than usual. 

1460.] It has been remarked, that in warm climates and 
seasons, after extremely hot and dry weather, a fall of rain 
cooling the atmosphere seems especially to bring on this 
disease ; and it is very probable than an obstructed perspi- 
ration may have also a share in this, though it is also certain 
that the disease does appear when no change in the tempe- 
rature of the air, nor any application of cold has been ob- 
served, 

1461.] It is possible, that, in some cases, the heat of the 
season may give only a predisposition, and that the disease 
may be excited by certain ingesta or other causes ; but it is 
equally certain, that the disease has occurred without any 



PRACTICE OF PHYSIC. 453 

}>revious change or error, either in diet, or in the manner of 
ife, that could be observed. 

1462.] The Nosologists have constituted a Genus under 
the title of Cholera, and under this have arranged as a spe- 
cies every affection in which a vomiting and purging of any- 
kind happened to concur. In many of these species, how- 
ever, the matter evacuated is not bilious ; nor does the 
evacuation proceed from any cause in the state of the at- 
mosphere. Further, in many of these species also, the vo- 
miting which occurs is not an essential, but merely an acci- 
dental symptom from the particular violence of the disease. 
The appellation of Cholera therefore should, in my opinion, 
be confined to the disease I have described above ; which 
by its peculiar cause, and perhaps also by its symptoms, is 
very different from all the other species that have been 
ciated with it. I believe that all the other species arm: 
under the title of Cholera by Sauvages or Sagar, may be 
properly enough referred to the genus of Diarrhoea ; which 
we are to treat of in the next chapter. 

The distinction I have endeavored to establish between 
the proper Cholera, and the other diseases that have some- 
times got the same appellation, will, as I judge, supersede 
the question, Whether the. Cholera, in temperate climates, 
happens at anv other season than that above assigned ? 

1463.] In the case of a genuine cholera, the cure of it 
ha6 been long established by experience. 

In the beginning of the disease, the evacuation of the 
redundant bile is to be favored by the plentiful exhibition 
of mild diluents,* both given by the mouth, and injected 
by the anus; and all evacuant medicines, employed in ei- 
ther way, are not only superfluous, but commonly hurtful. 
1464.] When the "redundant bile appears to be suffi- 
ciently washed out, and even before that, if the spasmodic 
affections of the alimentary canal become very violent, and 
are communicated in a considerable degree to other parts 
of the body, or when a dangerous debility seems to be in- 
duced, the irritation is to be immediately obviated by 
opiates in sufficiently large doses, but in small bulk, and 
given either by the mouth, or by glyster.f 

• Thin rice gruel is as proper a mild diluent as any we can use ; as is also water in which a. 
orust of bread is boiled. A very small quantity ot port wine may he added to these diluents tr 
the pul-e be small or weak. . „ ., . t 

+ A pill consisting of a grain of opium may be given every two hours, and if it dots not re- 
litre the symptoms' after the third or fourth repetition, we may inject the following gtyslCT . 

R. Decoct. Hord. §x. 
Tinct. Thebaic. 3ii. 



45* PRACTICE OF PHYSIC. 

' 1465.] Though the patient be in this manner relieved, 
it frequently happens, that when the operation of the opi- 
um is over, the disease shows a tendency to return ; and, 
for at least some days after the first attack, the irritability 
of the intestines,, and their disposition to fall into painful 
spasmodic contractions, seem to continue. In this situa- 
tion, the repetition of the opiates, for perhaps several 
days, may come to be necessary; and as the debility com- 
monly induced by the disease favors the disposition to 
spasmodic affections, it is often useful and necessary, to- 
gether with the opiates, to employ the tonic powers of the 
Peruvian bark.* 



CHAPTER XI. 
OF D1ARRHCEA, OR LOOSENESS. 

1466.] r THHIS disease consists in evacuation by stool, 
A more frequent and of more liquid matter than 
usual. This leading and characteristic symptom is so diver- 
sified in its degree, in its causes, and in the variety of mat- 
ter evacuated, that it is almost impossible to give any ge- 
neral history of the disease. 

1467.] It is to be distinguished from dysentery, by not 
being contagious ; by being generally without fever ; and 
by being with the evacuation of the natural excrements, 
which are, at least, for some time, retained in dysentery. 
The two diseases have been commonly distinguished by the 
gripings being more violent in the dysentery ; and they are 
commonly less violent and less frequent in diarrhoea : but as 
they frequently do occur in this also, and sometimes to a 
considerable degree, so they do not afford any proper dis- 
tinction, f 

1468.] A diarrhoea is to be distinguished from cholera 
chiefly by the difference of their causes ; which, in cholera, 

M. f. Enema. 

This Oyster may be repealed twice, or ihrice if there should be occasion. 
• The bark in these cases is often successfully given along with rhubarb, as in the following for- 
mula : 

R. Pulv. Cort. Peruv. 5 ft. 
Rad. Rhei, 3i. 
M. f. Pulv. in part, aequal. xii. dividend. 

One of there powders may be given three tunes a day with a glass of port wine. 
+ Tenesmus rsa distinguishing symptom of dysentery, but it is sometimes present in diarrhoea 
±'.sui «specially those diarrhoeas which proceed from acrid or putrid substances in the intestines. 



PRACTICE OF PHYSIC. 455 

» of one peculiar kind ; but in diarrhoea is prodigiously di- 
versified, as we shall see presently. It has been common 
to distinguish cholera by the evacuation downwards being 
of bilious matter, and by this being always accompanied 
with a vomiting of the same kind ; but it does not univer- 
sally apply, as a diarrhoea is sometimes attended with vo- 
miting, and even of bilious matter. 

1469.] The disease of diarrhoea, thus distinguished, is 
very greatly diversified ; but in all cases, the frequency of 
stools is to be imputed to a preternatural increase of the pe- 
ristaltic motion in the whole, or at least in a considerable 
portion, of the intestinal canal. This increased action is 
in different degrees, is often convulsive and spasmodic, and 
at any rate is a motus abnormis : for which reason, in the 
Methodical Nosology, I have referred it to the order of Spas- 
ini, and accordingly treat of it in this place. 

1470.] Upon the same ground, as I consider the disease 
named Lientery to be an increased peristaltic motion over 
the whole of the intestinal canal, arising from a peculiar 
irritability, I have considered it as merely a species of di- 
arrhoea. The idea of a laxity of the intestinal canal be- 
ing the cause either of lientery, or other species of diar- 
rhoea, appears to me to be without foundation, except in the 
single case of frequent liquid stools from a palsy of the 
sphincter am. 

1471.] The increased action of the peristaltic motion, I 
consider as always the chief part of the proximate cause of 
diarrhoea : but the disease is further, and indeed chiefly, 
diversified by the different causes of this increased action ; 
which we are now to inquire into. 

1472.] The several causes of the increased action of the 
intestines may be referred, I think, in the first place, to 
two general heads. 

The first is, of the diseases of certain parts of the body 
which, either from a consent of the intestines with these 
parts, or from the relation which the intestines have to the 
whole system, occasion an increased action in the intes- 
tines, without the transference of any stimulant matter from 
the primary diseased part to them. 

The second head of the causes of the increased action of 
the intestines is the stimuli of various kinds, which are ap- 
plied directly to the intestines themselves. 

1473.] These affections of other parts of the system 
may affect the intestines without transference or appli- 



456 PRACTICE OF PHYSIC. 

cation of any of the stimulant matter, we learn from hence 
that the passions of the mind do in some persons excite 
diarrhoea. 

1474.] That diseases in other parts may in like manner 
affect the intestines, appears from the dentition of infants 
frequently exciting diarrhoea. I believe that the gout of- 
ten affords another instance of the same kind ; and proba- 
bly there are others also, though not well ascertained. 

1475.] The stimuli (1472.) which may be applied to 
the intestines are of very various kinds ; and are either, 

1. Matters introduced by the mouth. 

2. Matters poured into the intestines by the several ex- 
cretories opening into them. 

3. Matters poured from certain preternatural openings 
made into them in certain diseases. 

1476.] Of those (1475, 1.) introduced by the mouth, 
the first to be mentioned are the aliments commonly taken 
in. Too great a quantity of these taken in, often prevents 
their due digestion in the stomach ; and by being thus sent 
in their crude, and probably acrid, state to the intestines, 
they frequently excite diarrhoea. 

The same aliments, though in proper quantity, yet hav- 
ing too great a proportion, as frequently happens, of sa- 
line or saccharine matter along with them, prove stimulant 
to the intestines, and excite diarrhoea. 

But our aliments prove especially the causes of diarrhoea, 
according as they, from their own nature, or from the 
weakness of the stomach, arc disposed to undergo an undue 
degree of fermentation there, and thereby become stimu- 
lant to the intestines. Thus acescent aliments are ready to 
produce diarrhoea ; but whether from their having any di- 
rectly purgative quality, or only as mixed in an over pro- 
portion with the bile, is not well determined. 

1477.] Not only the acescent, but also the putrescent 
disposition of the aliments, seems to occasion a diarrhoea ; 
and it appears that even the effluvia of putrid bodies, taken 
in any way in large quantity, have the same effect. 

Are oils or fats, taken in as part of our aliments, ever 
the cause of diarrhoea ? and if so, in what manner do they 
operate ?* 

1478.] The other matters introduced by the mouth, 
which may be causes of diarrhoea, are those thrown in either 
as medicines, or poisons that have the faculty of stimulat- 

*Rancid oils and fats certainly irritate the intestines, and may therefore produce diarrh<ra. 



PRACTICE OF PHYSIC. 457 

iftg the alimentary canal. Thus, in the list of the Materia 
Medica, we have a long catalogue of those named purga- 
tives ; and in the list of poisons, we have many possessed 
of the same quality. The former, given in a certain quan- 
tity, occasion a temporary diarrhoea ; and given in very 
large doses, may occasion it in excess, and continue it 
longer than usual, producing that species of diarrhoea nam- 
ed a Hypercatharsis. 

1479.] The matters (1475, 2.) poured into the cavity of 
the intestines from the excretories opening into them, and 
which may occasion diarrhoea, are either those from the 
pancreatic or biliary duct, or those from the excretories in 
the coats of the intestines themselves. 

1 480.] What changes may happen in the pancreatic juice 
I do not exactly know ; but I suppose that an acrid fluid 
may issue from the pancreas, even while still entire in its 
structure ; but more especially when it is in a suppurated, 
scirrhous, or cancerous state, that a very acrid matter may 
be poured out by the pancreatic duct, and occasion diarrhoea. 

1481.] We know well, that from the biliary duct the bile 
may be poured out in greater quantity than usual : and 
there is little doubt of its being also sometimes poured out 
of a more than ordinary acrid quality. It is very probable, 
that in both ways the bile is frequently a cause of diarrhoea. 

Though I have said above that diarrhoea may be com- 
monly distinguished from cholera, I must admit here, that 
as the causes producing that state of the bile which occa- 
sions cholera, may occur in all the different possible de- 
grees of force, so as, on one occasion, to produce the most 
violent and distinctly marked cholera ; but, upon another, 
to produce only the gentlest diarrhoea : which, however, 
will he the same disease, only varying in degree : so I think 
it probable, that in warm climates, and in warm seasons, a 
diarrhoea biliosa of this kind may frequently occur, not to 
be always certainly distinguished from cholera. 

However this maybe, it is sufficiently probable, that, in 
some cases, the bile, without having been acted upon by the 
heat of the climate or season, may be redundant and acrid, 
and prove therefore a particular cause of diarrhoea. 

1482.] Beside bile from the several causes and in the 
conditions mentioned, the biliary duct may pour out pus, 
or other matter from abscesses in the liver, which may be 
the cause of diarrhoea. 

Practical writers take notice of a diarrhoea wherein a thin 
3n 



458 PRACTICE OF PHYSIC. 

and bloody liquid is discharged ; which they suppose to 
have proceeded from the liver, and have therefore given 
the disease the name of Hepatirrhoea : but we have not met 
with any instance of this kind ; and therefore cannot pro- 
perly say any thing concerning it. 

1483.] A second set of excretories, from which matter is 
poured into the cavity of the intestines, are those from the 
coats of the intestines.themselves ; and are either the exha- 
lants proceeding directly from the extremities of arteries, 
or the excretories from the mucous follicles : and both these 
sources occur in prodigious number over the internal sur- 
face of the whole intestinal canal. It is probable that it is 
chiefly the effusion from these sources which, in most in- 
stances, gives the matter of the liquid stools occurring in 
diarrhoea. 

1484.] The matter from both sources may be poured out 
in larger quantity than usual, merely by the increased ac- 
tion of the intestines, whether that be excited by the pas- 
sions of the mind (1473.) by diseases in other parts of the 
system (1472, I.) or by the various stimulants mentioned 
1476, and following; or the quantity of matter poured 
out may be increased, not so much by the increased action 
of the intestines, as by an increased afflux of fluids from 
other parts of the system. 

Thus, cold applied to the surface of the body, and sup- 
pressing perspiration, may determine a greater quantity of 
fluids to the intestines. 

Thus, in the ischuria renalis, the urine taken into the 
blood-vessels is sometimes determined to pass off again by 
the intestines. 

In like manner, pus or serum may be absorbed from the 
cavities in which they have been stagnant, and be again 
poured out into the intestines, as frequently happens, in 
particular with respect to the water of dropsies. 

1485.] It is to be observed here, that a diarrhoea may be 
excited not only by a copious afflux of fluids from other 
parts of the system, but likewise by the mere determination 
of various acrid matters from the mass of blood into the ca- 
vity of the intestines. Thus it is supposed that the mor- 
bific matter of fevers is sometimes thrown out into the cavity 
of the intestines, and gives a critical diarrhoea : and whether 
I do or do not admit the doctrine of critical evacuations I 
think it is probable that the morbific matter of the exanthe- 



PRACTICE OF PHYSIC. 459 

mata is frequently thrown upon the intestines, and occa- 
sions diarrhoea. 

I486.] It is to me further probable, that the putrescent 
matter diffused over the mass of blood in putrid diseases, 
is frequently poured out by the cxhalants into the intestines, 
and proves there the cause, at least in part, of the diar- 
rhoea so commonly attending these diseases. 

1487.] Upon this subject of the matters poured into the 
cavity of the intestines, I have chiefly considered them as 
poured out in unusual quantity, but it is probable that, for 
the most part, they are also changed in their quality, and 
become of a more acrid and stimulant nature ; upon which 
account especially it is that they excite, or at least increase 
a diarrhoea. 

1488.] How far, and in what manner, the exhalant fluid 
may be changed in its nature and quality, we do not cer- 
tainly know; but with respect to the fluid from the mucous 
excretories, we know, that when poured out in unusual 
quantity, it is commonly, at the same time, in a more li- 
quid and acrid form; and may prove, therefore, consider- 
ably irritating. 

1489.] Though the copious effusion of a more liquid 
and acrid matter from the mucous excretories, be proba- 
bly owing to the matter being poured out immediately as 
it is secreted from the blood into the mucous follicles, with- 
out being allowed to stagnate in the latter, so as to acquire 
that milder quality and thicker consistence we commonly 
find in the mucus in its natural state ; and although we 
might suppose the excretions of a thin and acrid fluid 
should always be the effect of every determination to the 
mucous follicles, and of every stimulant applied to them ; 
yet it is certain, that the reverse is sometimes the case ; and 
that from the mucous follicles, there is frequently an in- 
creased excretion of a mucus, which appears in its proper 
form of a mild, viscid, and thickish matter. This com- 
monly occurs in the case of dysentery ; and it has been ob- 
served to give a species of diarrhoea, which has been pro- 
perly named the Diarrhoea Mucosa. 

1490.] A third source of matter poured into the cavity 
of the intestines, and occasioning diarrhoea (1475. 3.) is 
from those preternatural openings produced by diseases in 
the intestines or neighboring parts. Thus the blood-ves- 
sels on the internal surface of the intestines may be opened 
by erosion, rupture, or anastomosis, and pour into the ca- 



460 PRACTICE OF PHYSIC. 

vity their blood, which, either by its quantity, or by its 
acrimony, whether inherent, or acquired by stagnation, 
may sometimes give a diarrhoea evacuating bloody matter. 
This is what I think happens in that disease which has been 
called the Meloena or Morbus Niger. 

1491.] Another preternatural source of matter poured 
into the cavity of the intestines, is the rupture of abscesses 
seated either in the coats of the intestines themselves, or in 
any of the contiguous viscera, which, during an inflamed 
state, had formed an adhesion with some part of the intes- 
tines. The matter thus poured into their cavity may be 
various ; purulent, or sanious, or both together, mixed at 
the same time with more or less of blood; and in each of 
thesie states may be a cause of diarrhoea. 

1492.] Amongst the stimuli that may be directly applied 
to the intestines, and which, by increasing their peristaltic 
motion, may occasion diarrhoea, I must not omit to men- 
tion worms as having frequently that effect. 

149.3.] I must also mention here a state of the intestines, 
wnerein their peristaltic motion is preternaturally increas- 
ed, and a diarrhoea produced ; and that is, when they are 
affected with an erythematic inflammation. With respect 
to the existence of such a state, and its occasioning diar- 
rhoea, see what is said above in 398, and following. Whe- 
ther it is to be considered as a particular and distinct case 
of diarrhoea, or is always the same with some of those pro- 
duced by one or other of the causes above-mentioned, I 
have not been able to determine. 

1494.] Lastly, by an accumulation of alimentary or of 
other matter poured into the cavity of the intestines from 
several of the sources above-mentioned, a diarrhoea may 
be especially occasioned when the absorption of the lacteals, 
or of other absorbents, is prevented, either by an obstruc- 
tion of their orifices, or by an obstruction of the mesen- 
teric glands through which alone the absorbed fluids can be 
transmitted. 

In one instance of this kind, when the chyle prepared in 
the stomach and duodenum is not absorbed in the course 
of the intestines, but passes off in considerable quantity by 
the anus, the disease has been named Morbus Cceliacus, or 
simply and more properlv Cceliaca ; which accordingly I 
have considered as a species of diarrhoea. 

1495.] I have thus endeavored to point out the various 
species of disease that may come under the general appella- 



PRACTICE OF PHYSIC. 461 

tion of Diarrhoea ; and from that enumeration it will ap- 
pear, that many, and indeed the greater part of the ^ases 
of diarrbcea, are to be considered as sympathetic affections, 
and to be cured only by curing the primary disease upon 
which they depend ; of which, however, I cannot properly 
treat here. From our enumeration it will also appear, that 
many of the cases of diarrhoea which may be considered as 
idiopathic, will not require my saying much of them here. 
In many instances, the disease is ascertained, and also the 
cause assigned, by the condition of the matter evacuated ; 
so that what is necessary to correct or remove it will be suf- 
ficiently obvious to practitioners of any knowledge. In 
short, I do not find that I can offer any general plan for the 
cure of diarrhoea ; and all that I can pretend to do on this 
subject, is to give some general remarks on the practice that 
has been commonly followed in the cure of this disease. 

1496.] The practice in this disease has chiefly proceeded 
upon the supposition of an acrimony in the fluids, or of a 
laxity in the simple and moving fibres of the intestines ; 
and the remedies employed have accordingly been, Correc- 
tors of particular acrimony, general demulcents, evacuants 
by vomiting or purging, astringents, or opiates. Upon each 
of these kinds of remedies I shall now offer some remarks. 
1497.] An acid acrimony -is, upon several occasions, the 
cause of diarrhoea, particularly in children ; and in such 
cases the absorbent earths have been very properly employ- 
ed. The common, however, and promiscuous use of these, 
hath been very injudicious ; and where there is any putres- 
cencv, they must be hurtful. 

1498.] The cases in which there is a putrid or putrescent 
acrimony prevailing, have been, I think too seldom taken 
notice of ; and, therefore, the use of acids too seldom ad- 
mitted. The acrimony to be suspected in bilious cases, is 
probably of the putrescent kind. 

1499.] The general correctors of acrimony are the mild 
diluents and demulcents. The former have not been so 
much employed in diarrhoea as they, ought ; for, joined 
with demulcents, they very much increase the effects of the 
latter: and although the* demulcents, both mucilaginous 
and oily, may by themselves be useful, yet without the as- 
sistance of diluents they can hardly be introduced in such 
quantity as to answer the purpose.* 

• Lintseed tea is both diluent and demulrent ; but as the patient sometimes loaths it, we may 
in it, pl» i. uon of marsh-mallow root, or of quince seed. These intusions and de- 

coctions outlit to be extremely thin. An ounce of bruised quince seed will make three pin* 



462 PRACTICE OF PHYSIC. 

1500.] As indigestion and crudities present in the stomach 
are so often the cause of diarrhoea, vomiting must therefore 
be frequently very useful in this disease. 

In like manner, when the disease proceeds, as it often 
does, from obstructed perspiration, and increased afflux of 
fluids to the intestines, vomiting is perhaps the most effec- 
tual means of restoring the determination of the fluids to 
the surface of the body. 

It is possible also, that vomiting may give some inversion 
of the peristaltic motion, which is determined too much 
downwards in diarrhoea ; so that upon the whole it is a re- 
medy which may be very generally useful in this disease.* 

1501.] Purging has been supposed to be more univer- 
sally necessary, and has been more generally practised. 
This, however, in my opinion, proceeds upon very mis- 
taken notions with respect to the disease ; and such a prac- 
tice seems to me for the most part superfluous, and in ma- 
ny cases very hurtful. It goes upon the supposition of an 
acrimony present in the intestines, that ought to be carried 
out by purging : but, if that acrimony has either been in- 
troduced by the mouth, or brought into the intestines from 
other parts of the body, purging can neither be a means of 
correcting nor of exhausting it ; and must rather have the 
effect of increasing its afflux, and of aggravating its effects. 
From whatever source the acrimony which can excite a di- 
arrhoea proceeds, it may be supposed sufficient to evacuate 
itself, so far as that can be done by purging ; and as in 
cholera, so in the same kind of diarrhoea, it will be more 
proper to assist the evacuation by diluents and demulcents, 
than to increase the irritation by purgatives. 

1502.] If, then, the use of purgatives in diarrhoea may 
be considered, even when an acrimony is present, as super- 
fluous, there are many other cases in which it may be ex- 
tremely hurtful. If, the irritability of the intestines shall, 

of water as thick and ropy as the white of an egg : hence a drachm i3 sufficient for a pint of the 
decoction. 

We have another instance of a diluent and demulcent in the ajmond emulsion, which is an 
exceedingly elegant medicine. # Thc formula; in both the London and Edinburgh Pharmacopoeias 
are not well adapted to cases of diarrhoea : for the former contains sugar, and the latter bitter 
almonds; both of which ingredients increase the irritation. In these cases, therefoie, an cmul- 
iion made with sweet almonds and gum arabic, is preferable to either of the others : as, 

ft. Amygdal. dulc. decorticat. §i. 
Gum Arabic. 3i. 

Tere in mortario marmoreo, et adde gradatim, 
Aq. font. lb. i. 
M. f. Emuls. 

* The methods of giving the tartar emetic, for produci-ng either vomiting or sweating, may be 
iicr. :n ths notes on article 1S5. 



PRACTICE OF PHYSIC. 463 

from affections in other parts of the system, or other causes- 
have been already very much increased, purgatives must 
necessarily aggravate the disease. In the case of lienterv, 
nobody thinks of giving a purgative ; and in many cases of 
diarrhoea approaching to that, they must be equally impro- 
per. I have already observed, that when diarrhoea pro- 
ceeds from an afflux of fluids to the intestines, whether in 
too great quantity, or of an acrid quality, purgatives may 
be hurtful ; and, whoever, therefore, considers the nume- 
rous and various sources from which acrid matter may be 
poured into the cavity of the intestines, will readily per- 
ceive, that in many cases of diarrhoea, purgatives may be 
extremely pernicious. 

There is one case in particular to be taken notice of. 
When, from a general and acrid dissolution of the blood, 
the serous fluids run off too copiously in the cavity of the 
intestines, and excite that diarrhoea which attends the ad- 
vanced state of hectic fever, and is properly called a Colli- 
quative Diarrhoea ; I have, in such cases, often seen purga- 
tives given with the most baneful effects. 

There is still another case of diarrhoea in which purga- 
tives are pernicious ; and that is, when the disease depends, 
as we have alledged it sometimes may, upon an erythema- 
tic inflammation of the intestines. 

I need hardly add, that if there be a case of diarrhoea 
•depending upon a laxity of the solids, purgatives cannot 
there be of any service, and may do much harm. Upon 
the whole, it will, I think, appear, that the use of purga- 
tives in diarrhoea is very much limited ; and that the promiscu- 
ous use of them, which has been so common, is injudicious, 
and often pernicious. I believe the practice has been chiefly 
owing to the use of purgatives in dysenteric cases, in which 
they arc truly useful ; because, contrary to the case of di- 
arrhoea, there is in dysentery a considerable constriction of 
the intestines.* 

150'}.] Another set of remedies employed in diarrhoea 
are astringents. There has been some hesitation about the 

• Nnthwithstanding all the author advances concerning the danger of purgatives in a diarrhoea, 
there ire some cases in which they are of singular utility. His arguments in this article are 
doubtless jusi ; and, in the species of diarrhora which he here enumerates, purgatives are cer- 
umu' hurtful : but many instances of diarrhora occur, which proceed from an acrimony that is 
extremely tenacious, and that adheres c'osely to the internal surlacc of the intestines, or is re- 
tained in their folds. In such cases, purgatives are the only remedies for removing the disease, 
and ought therefore to he used. In all other cases, as the author justly observes, they are cer- 
tainly pernicious. Having ascertained -whm purgatives are proper, the next consideration is. 
-wh.it puigattvvs ought to be used r The answer is obvious :— Neutral salts, particularly Soda 
phosphorata, Rochet salt, Glauber's salts, and Epsom salt, which are enumerated in the order 
nt their being agreeable, but tn a contrary orsier to their degree of efljcacv ; the Epsom salt be- 
•ng the least agreeable, but the most eOicacious. 



464 PRACTICE OF PHYSIC. 

employment of these in recent cases, upon the supposition 
that they might occasion the retention of an acrid matter 
that should be thrown out. I cannot, however, well un- 
derstand or assign the cases in which such caution is neces- 
sary and I think that the power of astringents is seldom 
so great as to render their use very dangerous. 

The only difficulty which has occurred to me, with res- 
pect to their use, has been to judge of the circumstances to 
which they are especially adapted. It appears to me to be 
only in those where the irritability of the intestines depends 
upon a loss of tone; and this, I think, may occur from 
the debility of the whole system, or from causes acting on 
the intestines alone. All violent or long continued spas- 
modic and convulsive affections of the intestinal canal ne- 
cessarily' induce a debility there; and such causes often 
take place, from violent irritation, in colic, dysentery, 
cholera, and diarrhoea.* 

1504.] The last of the remedies of diarrhoea that remain 
to be mentioned are opiates. The same objections have 
been made to the use of these, in recent cases of diarrhoea, 
as to that of astringents; but on no good grounds: for the 
effect of opiates, as astringent, is never very permanent ; 
and an evacuation depending upon irritation, though it may 
be for some time suspended by opiates, yet always returns 
very soon. It is only by taking off irritability that opiates 
are useful in diarrhoea ; and therefore, when the disease de- 
pends upon an increase of irritability alone, or when, though 
proceeding from irritation, that irritation is corrected or ex- 
hausted, opiates are the most useful and certain remedy. 
And though opiates are not suited to correct or remove an 
irritation applied, they are often of great benefit in suspend- 
ing the effects of that irritation whenever these are violent ; 

•The astringents to be used, when they are proper, are various : as Alum, Logwood, Cate- 
chu, Rhubarb, Sec. The author justly remarks, that astringents are only useful incases of debi- 
lity, and therefore the tonic astringents are undoubtedly prefer Jble to any other. Rhubarb and 
Peruvian bark, each possessing both these qualities, may therefore be advantageously used con- 
jointly, as in the following formula .- 

R. Pulv. Cort. Peruv. %i. 
Rad. Rhei, Sft 

M. f. Pulv. 

The dose of this powder may be varied according to circumstances, from a scruple to a drachm, 
twice a day, with a glass of Port wine after it. It may not be improper to observe, that in diar- 
rhoeas in general, peculiar attention must be paid to diet. The oleraceous and acescent vege- 
tables must be carefully avoided ; as must also all fermented liquors except Port wine : of the 
farinaceous vegetables, rice is the best ; and rice-water, with a iii tie cinnamon and Port wine, 
is the most proper drink for patients in these cases. Roasted meats are preferable to boiled; 
and veal, lamb, or chickens, preferable to beef or mutton. Pork is very improper ; as are also 
aJI kinds of fish. Puddings of all kinds without fruit are very proper food for such patients, es- 
pecially rice-puddings made without eggs, but with milk, and cinnamon ; and also rice-milk, 
■**io with Port wine, blanc mange, &c. 



PRACTICE OF PHYSIC. 46p 

and, upon the whole, it will appear, that opiates may be 
very frequently, and with great propriety, employed in the 
cure of diarrhoea. 



CHAPTER XII. 

OF THE DIABETES. 

1505.] r I ^HIS disease consists in the voiding of an un- 
JL usually large quantity of urine. 

As hardly any secretion can be increased without an in- 
creased action of the vessels concerned in it, and as some 
instances of this disease are attended with affections mani- 
festly spasmodic, I have had no doubt of arranging the 
diabetes under the order of Spasmi. 

1506.] This disease is always accompanied with a great 
degree of thirst, and therefore with the taking in of a great 
quantity of drink. This in some measure accounts for the 
very extraordinary quantities of urine voided : but still, in- 
dependent of this, a peculiar disease certainly takes place ; 
as the quantity of urine voided does almost always exceed 
the whole ot the liquids, and sometimes the whole of both 
solids and liquids, taken in. 

1507.] The urine voided in this disease is always very 
clear, and at first sight appears entirely without any color : 
but viewed in a certain light, it generally appears to be 
slightly tinged with a yellowish green, and in this respect 
has been very properly compared to a solution of honey in 
a large proportion of water. 

Examined by the taste, it is very generally found to be 
more or loss sweet ; and many experiments that have now 
been made in different instances of the disease show clearly 
that such urine contains, in considerable quantity, a sac- 
charine matter which appears to be very exactly of the na- 
ture of common sugar. 

1508.] Doctor Willis seems to me to have been the first 
who took notice of the sweetness of the urine in diabetes, 
and almost every physician of England has since taken no- 
tice of the same. It is to be doubted, indeed, if there is 
anv case of idiopathic diabetes in which the urine is of a 
different kind. Though neither the ancients, nor, in the 
other countries of Europe, the moderns, till the latter were 
directed to it by the English, have taken notice of the 

So 



466 PRACTICE OF PHYSIC. 

sweetness of the urine, it does not persuade me, that either 
in ancient or in modern times the urine in diabetes was of 
another kind. I myself, indeed, think I have met with one 
instance of diabetes in which the urine was perfectly insi- 
pid ; and it would seem that a like observation had occur- 
red to Dr. Martin Lister. I am persuaded, however, that 
such instances are very rare ; and that the other is by much 
the more common, and perhaps the almost universal occur- 
rence. I judge, therefore, that the presence of such a sac- 
charine matter may be considered as the principal circum- 
stance in idiopathic diabetes ; and it gives at least the only 
case of that disease that I can properly treat of here, for 1 
am only certain that what I am further to mention relates to 
such a case. 

J 509.] The antecedents of this disease, and consequent- 
ly the remote causes of it, have not been well ascertained. 
It may be true that it frequently happens to men who, for 
a long time before, had been intemperate in drinking ; that 
it happens to persons of a broken constitution, or who, as 
we often express it, are in a cachectic state ; that it some 
times follows intermittent fevers ; and that it has often oc- 
curred from excess in drinking of mineral waters. But 
none of these causes apply very generally to the cases that 
occur : such cases are not always, nor even frequently, 
followed by a diabetes ; and there are many instances of 
diabetes ; which could not be referred to any of them. 
In most of the cases of this disease which I have met 
with, I could not refer it to any particular cause. 

1510.] This disease commonly comes on slowly, and al- 
most imperceptibly, without any previous disorder. It 
often arises to a considerable degree, and subsists long 
without being accompanied with evident disorder in any 
particular part of the system. The great thirst which al- 
ways, and the voracious appetite which frequently, occur 
in it, arc often the only remarkable symptoms. Under 
the continuance of the disease, the body is often greatly 
emaciated ; and a great weakness also prevails. The pulse 
is commonly frequent ; and an obscure fever is for the most 
part present. When the disease proves fatal, it generally 
ends with a fever, in many circumstances, particularly 
those of emaciation and debility, resembling a hectic. 

1511.] The proximate cause of this disease is not cer- 
tainly or clearly known. It seems to have been sometimes 
connected with calculous affections of the kidneys j and it 



PRACTICE OF PHYSIC. 467 

is possible, that an irritation applied there may increase the 
secretion of urine. It perhaps often does so ; but how it 
should produce the singular change that takes place in the 
state of the urine, is not to be easily explained. It cer- 
tainly often happens, that calculous matters are long pre- 
sent in the urinary passages, without having any such ef- 
fect as that of producing diabetes in any shape. 

Some have supposed that the disease occurs from a relax- 
ed state of the secretory vessels of the kidneys ; and indeed 
the dissections of persons who had died of this disease have 
shown the kidneys in a very flaccid state. This however, 
is probably to be considered as rather the effect than the 
cause of the disease. 

That no topical affection of the. kidneys has a share in 
producing this disease, and that a fault in the assimilation 
of the fluids is rather to be blamed, I conclude from henee, 
that even the solid food taken in, increases the quantity of 
the urine voided, at the same time with an increase of the 
saccharine matter above-mentioned. 

1 5 12.] The diabetes has been supposed to be owing to a 
certain state of the bile : and it is true, that this disease lias 
sometimes occurred in persons who were at the same time 
affected with diseases of the liver : but this occurrence does 
not often take place ; and the diabetes frequentlv occurs 
separately from any affection of the liver. In twenty in- 
stances of diabetes which I have seen, there was not in any 
one of them any evident affection of the liver. 

The explanation that has been offered of the nature and 
operation of the bile, in producing diabetes, is very hypo- 
thetical, and no wise satisfying. 

1513.] As I have already said, I think it probable, that 
m most cases the proximate cause of this disease is some 
fault in the assimilatory powers, or in those employed in 
converting alimentary matters into the proper animal 
fluids. This I formerly hinted to Dr. Dobson, and it has 
been prosecuted and published by him ; but I must own 
i hat it is a theory embarrassed with some difficulties which 
I cannot at present very well remove. 

1614.] The proximate cause of diabetes being so little 
known or ascertained, I cannot propose any rational me- 
thod of cure in the disease.* From the testimony of several 

♦ The d pily not very common : hut, when .1 physician i< called, be is under the 

thmif, and not remaining inactive, '•"me general direct ions may tliere- 

enre will principally consist in avoiding 

illy by avoiding strong rim. Id As lite quantity erf 

innuion is incri to Seep 



46fc PRACTICE OF PHYSIC. 

authors, 1 believe that the disease has been cured : but I 
believe also, that this has seldom happened; and when the 
disease has been cured, I doubt much if it was effected by 
the several remedies to which these cures have been ascrib- 
ed. In all the instances of this disease which I myself hav6 
seen, and in several others of which I have been informed, 
no cure of it has ever been made in Scotland, though many 
instances of it have occurred, and in most of them the re- 
medies recommended by authors have been diligently em- 
ployed. I cannot, therefore, with any advantage, enter 
into a detail of these remedies ; and as the disease, toge- 
ther with its several circumstances, when they shall here- 
after occur, is likely to become the subject of diligent in- 
vestigation, I avoid going farther at present, and judge it 
prudent to suspend my opinion till I shall have more ob- 
servations and experiments upon which I can form it more 
clearly. 



CHAPTER XIII. 

OF THE HYSTERIA, OR THE HYSTERIC 
DISEASE. 

1515.] nr^HE many and various symptoms which have 
JL been supposed to belong to a disease under 
this appellation, render it extremely difficult to give a ge- 
neral character or definition of it. It is, however, proper 
in all cases to attempt some general idea ; and therefore, 
by taking the most common form, and that concurrence of 
symptoms by which it is principally distinguished, I have 
formed a character in my system of Methodical Nosology, 
and shall here endeavor to illustrate it by giving a more 
full history of the phenomena. 

1516.] The disease attacks in paroxysms or fits. These 
commonly begin by some pain and fulness felt in the left 
side of the belly. From this a ball* seems to move with 
a grumbling noise into the other parts of the belly; and, 
making as it were various convolutions there, seems to 
move into the stomach ; and more distinctly still rises up to 

the surface of the skin lax and perspirable ; and, if the patient's strength allows him, he ought 
frequently to use bodily exercise to promote sweat. For a similar reason, external cold must 
be avoided, because by diminishing perspiration, a larger quantity of fluids is derived to the 
kidney In some cases the disease ma\ be probably owing to a lax or weak state of the kid- 
neys; hence the indication of tunics, as Peruvian bark, and other tonic bitters. 
» Commonly called Globus hystericus by authors. 



PRACTICE OF PHYSIC. 469 

the top of the gullet, where it remains for some time and 
by its pressure upon the larynx gives a sense of suffocation. 
By the time that the disease has proceeded thus far, the 
patient is affected with a stupor and insensibility, while at 
the same time the body is agitated with various convulsions. 
The trunk of the body is wreathed to and fro, and the 
limbs are variously agitated; commonly the convulsive 
motion of one arm and hand, is that of beating with the 
closed fist, upon the beast very violently and repeatedly. 
This state continues for some time, and has during that 
time some remissions and renewals of the convulsive mo- 
tions; but they at length cease, leaving the patient in a stu- 
pid and seemingly sleeping state. More or less suddenly, 
and frequently with repeated sighing and sobbing, toge- 
ther with a murmuring noise in the belly, the patient re- 
turns to the exercise of sense and motion, but generally 
without any recollection of the several circumstances that 
had taken place during the fit. 

1517.] This is the form of what is called an hysteric 
paroxysm, and is the most common form ; but its parox- 
ysms are considerably varied in different persons, and even 
in the same person at different times. It differs, by hav- 
ing more or fewer of the circumstances above-mentioned; 
by these circumstances being more or less violent; and by 
the different duration of the whole fit. 

Before the fit there is sometimes a sudden and unusually 
large flow of limpid urine. At the coming on of the fit, 
the stomach is sometimes affected with vomiting, the lungs 
with considerable difficulty of breathing, and the heart 
with palpitations. During the fit, the whole of the belly, 
and particularly the navel, is drawn strongly inwards; the 
spincter ani is sometimes so firmly constricted as not to 
admit a small glyster-pipe, and there is at the same time an 
entire suppression of urine. Such fits are, from time to 
time, ready to recur ; and during the intervals, the patients 
are liable to involuntary motions, to fits of laughing and 
crying, with sudden transition from the one to the other ; 
while sometimes false imaginations, and some degree of de- 
lirium, also occur. 

1518.] These affections have been supposed peculiar to 
the female sex ; and indeed they most commonly appear in 
females: but they sometimes, though rarely, attack also the 
male sex ; never, however, that I have observed, in the same 
exquisite degree. 



470 PRACTICE OF PHYSIC. 

In the female sex, the disease occurs especially from the 
age of puberty to that of thirty-five years ; and though it 
does sometimes, yet it very seldom appears before the former 
or after the latter of these periods. 

At all ages, the time at which it most readily occurs is that 
of the menstrual period. 

The disease more especially affects the females of the 
most exquisitely sanguine and plethoric habits, and fre- 
quently affects those of the most robust and masculine con- 
stitutions. 

It affects the barren more than the breeding women, and 
therefore frequently young widows. 

It occurs especially in those females who are liable to the 
Nymphomania ; and the Nosologists have properly enough 
marked one of the varieties of this disease by the title of 
Hysteria Libidinosa. 

In the persons liable to the fits of this disease, it is rea- 
dily excited by the passions of the mind, and by every con- 
siderable emotion, especially those brought on by surprise. 

The persons liable to this disease acquire often such a de- 
gree of sensibility, as to be strongly affected by every im- 
pression that comes upon them by surprise. 

J 519.] In this history, there appears to be a concurrence 
of symptoms and circumstances properly marking a very 
particular disease, which I think may be distinguished from 
all others. It seems to me to have been improperly consi- 
dered by physicians as the same with some other diseases, 
and particularly with hypochondriasis. The two diseases 
may have some symptoms in common, but for the most part 
are considerably different. 

Spasmodic affections occur in both diseases : but neither 
so frequently, nor to so great a degree, in hypochondriasis 
as in hysteria. 

Persons liable to hysteria are sometimes affected at the 
same time with dyspepsia. They are often, however, en- 
tirely free from it ; but I believe this never happens to per- 
sons affected with hypochondriasis. 

These different circumstances mark some difference in the 
two diseases; but they arc still more certainly distinguished 
by the temperament* they attack, and by the timef of life 
at which they appear to be most exquisitely formed. 

It has been generally supposed, that the two diseases dif- 

* Hysteria attacks tlie S2n»uine and plethoric, but Hypochondriasis the melarti 
+ Hypochondriasis scarcely ever appears early in life, nor Hysteria late : and Hypochondriasis 
becomes aggravated, but Hysteria r 



PRACTICE OF PHYSIC. 471 

fer only in respect of their appearing in different sexes. But 
this is not well founded : for although the hysteria appears 
most commonly in females, the male sex is not absolutely 
free from it, as I have observed above ; and although the 
hypochondriasis may be most frequent in men, the instances 
of it in the female sex are very common.* 

1520.] From all these considerations, it must, I think, ap- 
pear, that the hysteria may be very well, and properly, dis- 
tinguished from hypochondriasis. 

Further, it seems to me to have been with great impro- 
priety, that almost every degree of the irregular motions 
of the nervous system has been referred to the one or 
other of these two diseases, Both are marked by a pecu- 
liarity of temperament, as well as by certain symptoms 
commonly accompanying that ; but some of these, and ma- 
ny others usually marked by the name of nervous symp- 
toms may, from various causes, arise in temperaments dif- 
ferent from that which is peculiar to either hysteria or hy- 
pochondriasis, and without being joined with the peculiar 
symptoms of either the one or the other disease : so that 
the appellations of Hysteric and Hypochondriac are very 
inaccurately applied to them. Under what view these 
symptoms are otherwise to be considered, I am not ready 
to determine ; but must remark, that the appellation of 
Nervous Diseases is too vague and undefined to be of any 
useful application. 

1521.] Having thus endeavored to distinguish hysteria 
from every other disease, I shall now attempt its peculiar 
pathology. With respect to this, I think it will, in the first 
place, be obvious, that its paroxysms begin by a convulsive 
and spasmodic affection of the alimentary canal, which is. 
afterwards communicated to the brain, and to a great part 
of the nervous system. Although the disease appears to 
begin -in the alimentary canal, yet the connection which 
the paroxysms so often have with the menstrual flux, and 
with the diseases that depend on the state of the genitals, 
shows, that the physicians have at all times judged rightly 
in considering this disease as an affection of the uterus and 
other parts of the genital system. 

1522.] With regard to this, however, I can go no farther. 
In what manner the uterus, and in particular the ovaria, are 
affected in this disease ; how the affection of these is com- 
municated, with particular circumstances, to the alimen- 

* The Hypochondriacs In women has been frequently mistaken for Hysteria. 



472 PRACTICE OF PHYSIC. 

tary canal ; or how the affection of this, rising upward*, 
affects the brain, so as to occasion the particular convul- 
sions which occur in this disease, I cannot pretend to 
explain. 

But although I cannot trace this disease to its first causes, 
or explain the whole of the phenomena, I hope, that with 
respect to the general nature of the disease, I may form 
general conclusions, which may serve to direct our con- 
duct in the cure of it. 

1523.] Thus, from a consideration of the predisponent 
and occasional causes, it will, I think, appear, that the 
chief part of the proximate cause is a mobility of the sys- 
tem, depending generally upon its plethoric state. 

1524.] Whether this disease ever arises from a mobilit\ 
of the system, independent of any plethoric state of it, I 
cannot positively determine ; but in many cases that have 
subsisted for some time, it is evident that a sensibility, and 
consequently a mobility, are acquired, which often appear 
when neither a general plethora can be supposed to subsist, 
nor an occasional turgescenee to have happened. How- 
ever, as we have shown above, that a distension of the ves- 
sels of the brain seems to occasion epilepsy, and that a 
turgescenee of the blood in the vessels of the lungs seems to 
produce asthma ; so analogy leads me to suppose, that a 
turgescenee of blood in the uterus, or in other parts of the 
genital system, may occasion the spasmodic and convul- 
sive motions which appear in hysteria. It will, at the 
same time, be evident, that this affection of the genitals 
must especially occur in plethoric habits ; and every cir- 
cumstance mentioned in the history of the disease serves to 
confirm this opinion with respect to its proximate cause. 

1525.] From this view of the subject, the analogy of 
hysteria and epilepsy will readily appear ; and why, there- 
fore, 1 am to say that the indications of cure are the same 
m both. 

As the indications, so the several means of answering 
them are so much the same in both diseases, that the same 
observations and directions, with regard to the choice and 
employment of these remedies, that have been delivered 
above on the subject of epilepsy, will apply pretty exactlv 
to hysteria ; and therefore need not to be repeated here.* 

* Although the indications of cure may be the same in both diseases, yet in hysteria \re are 
more frequently under the necessity of relieving the violence of the symptoms than in epilepsy i 
■in-l for this purpose we must have recourse to a variety of antispasmodics.— Asafoetida, in vari- 
ous formi. i< usually employed ; as ar* also volatile spirits : butboih these joined prove more 



PRACTICE OF PHYSIC. 473 



CHAPTER XIV. 

OF CANINE MADNESS AND HYDROPHOBIA. 

1526. HHHIS disease has been so exactly and fully de- 
JL scribed in books that are in every body's 
hands, that it is on no account necessary for me to give any 
history of it here ; and with respect to the pathology of it, I 
find that I can say nothing satisfying to myself, or that I 
can expect to prove so to others. I find also, with respect 
to the cure of this disease, that there is no subject in which 
the fallacy of experience appears more strongly than in this. 
From the most ancient to the present times, many reme- 
diesfor preventing and curing this disease have been recom- 
mended under the sanction of pretended experience, and 
have perhaps also kept their credit for some time : but suc- 
ceeding times have generally, upon the same ground of ex- 
perience, destroyed that credit entirely ; and most of the 
remedies formerly employed are now fallen into absolute 
neglect. In the present age, some new remedies have been 
proposed, and have experience alledged to vouch for their 
efficacy ; but many doubts still remain with respect to this : 
and though I cannot determine in this matter from my own 
experience, I think it incumbent on me to give the best 

efficacious than either of them singly. There are excellent formulae of this kind in the London 
and Edinburgh Pharmacopoeias, under the title of Spiritus Ammonia: foetidus. Its dose is twen- 
ty or thirty drops, repeated according to the urgency of the case, several times a day.— The 
Tinctura Castorei composita of the Edinburgh Pharmacopoeia is another excellent formula of 
the same kind : it is a remedy of real efficacv. The dose of it is thirty or forty drops related 
occasionally.— The Tinctura Volerianx volaiilis of both the Pharmacopoeias is also frequently 
used Its dose is a tea-spoonful or two.— Few of the compositions of the shops are found 10 be 
m. ire elticacious antispasmodics than the Spiritus ^Etheris Vitriolicus compotitus of the London 
Pharmacopoeia. Its dose is from thirty to fifty drops in two or three spoonfuls of cold water ; 
and it must be swallowed immediately on pouring out of the vial.— These and other antispas- 
modics may be used promiscuously: for, in different cases and constitutions, they prove differ- 
ently efficacious. Sometimes they may be variously combined with one another, and with 
opium Opium, however, ought not to be used, except where other antispasmodics fail, as it 
always leaves the patient remarkably low, and liable to returns of the paroxysms.— Besides the 
■se of ihese remedies internally, some of them may be usefully employed externally ; as strong 
rolatile spirits to the nose, the vitriolic ither to the temples, ice— These remedies are chiefly 
designed tor occasionally removing the violence of symptoms ; but the fetid gums, in substance, 
must be used, when we wish to produce permanent effects. The formulae of them are in both 
our Pharmacopeias, under the title of Gum-pills; but they will be found much more efficacious 
ky adding to them a Utile castor, as in the following formula : 

R. Pilul. Gummos. Edinb. Sf?>. 
Castor. Russic. $i. 
Syr. simpl. q. s. 
M. f. mass, in pilulas lxxv. equales dividend. 

Five of these pills may be taken twice a day, washing ihem down with a tea-cupful of cold 
water with a tea-spoonful of rolatile tincture of valerian in it.— The Pilulx teudx ot the Swed- 
ish Pharmacopeia, in which castor is one of the ingredients, is preferable to either ot our gum- 
mi). 

3* 



414 PRACTICE OF PHYSIC. 

judgment I can form with respect to the choice of the re- 
medies at present recom mended. 

1527.] I am in the first place, firmly persuaded, that 
the most certain means of preventing the consequences of 
the bite, is to cut out, or otherwise destroy, the part in 
which the bite has been made. In this every body agrees ; 
but with this difference, that some are of opinion that it 
can only be effectual when it is done very soon after the 
wound has been made, and they therefore neglect it when 
this opportunity is missed. There have been, however, 
no experiments made proper to determine this matter : and 
there are many considerations which lead me to think, 
that the poison is not immediately communicated to the 
system ; and therefore, that this measure of destroying the 
part mav be practised with advantage, even many days af- 
ter the bite has been given. 

1528.] Whilst the state of our experience, with respect 
to several remedies now in use, is uncertain, I cannot ven- 
ture to assert that any of these is absolutely ineffectu- 
al ; but 1 can give it as my opinion, that the efficacy of 
mercurv, given very largely, and persisted in for a long 
time, both as a means of preventing the disease, and of 
curing it when it has actually come on, is better supported 
by experience than that of any other remedy now proposed 
or commonly employed. 



BOOK IV. 

OF VES4NLE, OR OF THE DISORDERS OF 
THE INTELLECTUAL FUNCTIONS. 



CHAPTER I. 

OF VESANIJE IN GENERAL. 

1529.] 'T'VrlE Nosologists, Sauvages, and Sagar, in a 
JL class of diseases under the title of VesanijE, 
have comprehended the two orders, of Halluclnationes or 
False Perceptions, and of Morositutes or Erroneous Appe- 
tites and Passions ; and, in like manner, Linnaeus in his 
class of Mentales, corresponding to the Vesanige of Sau- 



PRACTICE OF PHYSIC. 475 

vages, has comprehended the two orders of Imaginarii 
and Patheticiy nearly the same with the Hallucinationes and 
Morositates of that author. This, however, from several 
considerations, appears to me improper ; and I have there- 
fore formed a class of Vesaniae nearly the same with the Pa- 
ranoic of Vogel, excluding from it the Hallucinationes and 
Morositates, which I have referred to the Morbi Locales. 
Mr. Vogel has done the like, in separating from the Para- 
jioiae the false perceptions and erroneous appetites ; and has 
thrown these into another class, to which he has given the 
title of Hyperaestheses. 

1530.] It is indeed true, that certain hallucinationes and 
morositates are frequently combined with what I propose to 
consider as strictly a vesania or an erroneous judgment ; 
and sometimes the hallucinationes seem to lay the founda- 
tion of, and to form almost entirely, the vesania. But as 
most part of the hallucinationes enumerated by the Nosolo- 
gists are affections pnrely topical, and induce no other error 
of judgment beside that which relates to the single object of 
the sense or particular organ affected ; so these are certain- 
ly to be separated from the diseases which consist in a more 
general affection of the judgment. Even when the halluci- 
nationes constantly accompany or seem to induce the vesa- 
nia, yet being such as arise from internal causes, and may 
be presumed to arise from the same cause as the more gene- 
ral affection of the judgment, they are therefore to be con- 
sidered as symptoms of this only. 

In like manner I judge with respect to the morositates, 
or erroneous passions, that accompany vesania ; which, as 
consequences of a false judgment, must be considered as 
arising from the same causes, and as symptoms only, of the 
more general affection. 

There is, indeed, one case of a morositas which seems to 
induce a vesania, or more general affection of the judg- 
ment ; and this may lead us to consider the vesania, in this 
case, as a symptom of an erroneous appetite, but will not 
afford any good reason for comprehending the morositates 
in general under the vesaniae, considered as primary diseases. 

The limitation, therefore, of the class of Vesania' to the 
lesions of our judging faculty, seems from every conside- 
ration to be proper. 

The particular diseases to be comprehended under this 
class, may be distinguished according as they alVcct persons 
in the time of waking or sleeping. Those which affect men 



476 PRACTICE OF PHYSIC, 

awake, may again be considered, as they consist in an erro- 
neous judgment, to which I shall give the appellation of 
Delirium; or as they consist in a weakness or imperfection 
of judgment, which I shall name Fatuity. I begin with 
the consideration of Delirium. 

] 531 .] As men differ greatly in the soundness and force of 
their judgment, so it may be proper here to ascertain more 
precisely what error or imperfection of our judging facul- 
ty is to be considered as morbid, and to admit of the appel- 
lations of Delirium and Fatuity. In doing this, I shall first 
consider the morbid errors of judgment under the general 
appellation of Delirium, which has been commonly em- 
ployed to denote every mode of such error. 
• 1532.J As our judgment is chiefly exercised in discern- 
ing and judging of the several relations of things, I appre- 
hend that delirium may be defined to be, — In a person 
awake, a false or mistaken judgment of those relations of 
things, which, as occurring most frequently in life, are 
those about which the generality of men form the same 
judgment ; and particularly when the judgment is very dif- 
ferent from what the person himself had before usually 
formed. 

1533.] With this mistaken judgment of relations there 
is frequently joined some false perception of external ob- 
jects, without any evident fault in the organs of sense, and 
which seems therefore to depend upon an internal cause ; 
that is, upon the imagination arising from a condition in 
the brain presenting objects which are not actually present. 
Such false perceptions must necessarily occasion a delirium, 
or an erroneous judgment, which is to be considered as the 
disease. 

1534.] Another circumstance, commonly attending de- 
lirium, is a very unusual association of ideas. As, with 
respect to most of the affairs of common life, the ideas laid 
up in the memory are, in most men, associated in the same 
manner ; so a very unusual association, in any individual, 
must prevent his forming the ordinary judgment of those 
relations which are the most common foundation of asso- 
ciation in the memory : and therefore this unusual and 
commonly hurried association of ideas, usually is, and may 
be considered as, a part of delirium. In particular it may 
be considered as a certain mark of a general morbid affec- 
tion of the intellectual organs, it being an interruption or 



PRACTICE OF PHYSIC. 477 

perversion of the ordinary operations of memory, the com- 
mon and necessary foundation of the exercise of judgment. 

1535.] A third circumstance attending delirium, is an 
emotion or passion, sometimes of the angry, sometimes of 
the timid kind ; and from whatever cause in the perception 
or judgment, it is not proportioned to such cause, either 
in the manner formerly customary to the person himself, or 
in the manner usual with the generality of other men. 

1536.] Delirium, then, may be more shortlv defined — 
In a person awake, a false judgment arising from percep- 
tions of imagination, or from false recollection, and com- 
monly producing disproportionate emotions. 

Such delirium is of two kinds; as it is combined with 
pyrexia and comatose affections; or, as it is entirely with- 
out any such combination. It is the latter case that we 
name Insanity; and it is this kind of delirium only that I 
am to treat of here. 

1537.] Insanity may perhaps be properly considered as 
a genus comprehending many different species, each of 
which may deserve our attention ; but before proceeding 
to the consideration of particular species, I think it pro- 
per to attempt an investigation of the cause of insanity in 
generdl. 

1538.] In doing this, I shall take it for granted, as de- 
monstrated elsewhere, that although this disease seems to 
be chiefly, and sometimes solely, an affection of the mind j 
yet the connection between the mind and body in this case 
is such, that these affections of the mind must be consi- 
dered as depending upon a certain state of our corporeal 
Eart. See Halleri Prim. Lin. Physiolog. § 570. See Boer- 
aavii Inst. Med. § 581. 696. 

1539.] Admitting this proposition, I must in the next 
place assume another, which I likewise suppose to be de- 
monstrated elsewhere. This is, that the part of our body 
more immediately connected with the mind, and therefore 
more especially concerned in every affection of the intel- 
lectual functions, is the common origin of the nerves ; 
which I shall, in what follows, speak of under the appel- 
lation of the Brain. 

1540.] Here, however, in assuming this last proposition, 
a very great difficulty immediately presents itself. Altho' 
we cannot doubt that the operations of our intellect always 
depend upon certain motions taking place in the brain, (see 
Gaub. Peth. Med. § 523 ;) yet these motions have never 



47S PRACTICE OF PHYSTC. 

been the objects of our senses, nor have we been able to 
perceive that any particular part of the brain has more con- 
cern in the operations of our intellect than any other. Nei- 
ther have we attained any knowledge of what share the se- 
veral parts of the brain have in tnat operation ; and there- 
fore, in this situation of our science, it must be a very diffi- 
cult matter to discover those states of the brain that may 
give occasion to the various state of our intellectual functions. 

1541.] It may be observed, that the different state of the 
motion of the blood in the vessels of the brain has some share 
in affecting the operations of the intellect : and physicians, 
in seeking for the causes of the different states of our intel- 
lectual functions, have hardly looked further than into the 
state of the motion of the blood, or into the condition of the 
blood itself: but it is evident that the operations of the intel- 
lectual functions ordinarily go on, and are often considera- 
bly varied, without our being able to perceive any difference 
either in the motions or in the conditions of the blood. 

1542.] Upon the other hand, it is very probable that the 
state of the intellectual functions depends chiefly upon tiie 
state and condition of what is termed the Nervous Power, 
or, as we suppose, of a subtile very moveable fluid, included 
or inherent, in a manner we do not clearly understand in 
every part of the medullary substance of the brain and 
nerves, and which in a living and healthy man is capable of 
being moved from every one part to every other of the ner- 
vous system. 

1543.] With respect to this power, we have pretty clear 
proof that it frequently has a motion from the sentient ex- 
tremities of the nerves towards the brain, and thereby pro- 
duces sensation ; and we have the same proof, that in con- 
sequence of volition the nervous power has a motion from 
the brain into the muscles or organs of motion. Accord- 
ingly, as sensation excites our intellectual operations, and 
volition is the effect of these, and as the connection between 
sensation and volition is always by the intervention of the 
brain and of intellectual operations ; so we can hardly 
doubt, that these latter depend upon certain motions, and 
the various modification of these motions, in the brain. 

1544.] To ascertain the different states of these motions 
may be very difficult ; and physicians have commonly con- 
sidered it to be so very mysterious, that they have generally 
despaired of attaining any knowledge with regard to it : 
but I consider such absolute despair, and the negligence it 



PRACTICE OF PHYSIC. 479 

inspires, to be always very blameable ; and I shall now 
venture to go some length in the inquiry, hoping that some 
steps made with tolerable firmness may enable us to go still 
further. 

1545.] To this purpose, I think it evident, that the ner- 
vous power, in the whole as well as in the several parts of 
the nervous system, and particularly in the brain, is at dif- 
ferent times in different degrees of mobility and force. To 
these different states, I beg leave to apply the terms of Ex- 
citement and Collapse. To that state in which the mobility 
and force are sufficient for the exercise of the functions, or 
when these states are any way preternaturally increased, I 
give the name of Excitement ; and to that state in which 
the mobility and force are not sufficient for the ordinary ex- 
ercise of the functions, or when they are diminished from 
the state in which they had been before, I give the name of 
Collapse. I beg, however, it may be observed, that by 
these terms I mean to express matters of fact only ; and 
without intending, by these terms, to explain the circum- 
stance or condition, mechanical or physical, of the nervous 
power or fluid in these different states. 

1546.] That these different states of excitement and col- 
lapse take place on different occasions, must, I think, be 
manifest from numberless phenomena of the animal eco- 
nomv : but it is especially to our present purpose to ob- 
serve, that the different states of excitement and collapse, 
are in no instance more remarkable, than in the different 
states of waking and sleeping. In dhe hitter, when quite 
complete, the motion and mobility of the nervous power, 
with respect to the whole of what are called the Animal 
Functions, entirely cease, or, as I would express it, are in 
a state of collapse ; and are very different from the state of 
waking, which in healthy persons I would call a state of 
general and entire excitement. 

1547.] This difference in the states of the nervous power 
in sleeping and waking being admitted, I must in the next 
place observe, that when these states are changed from the 
one into the other, as commonly happens every day, the 
change is hardly ever made instantaneously, but almost al- 
ways by degrees, and in some length of time only : and 
this mav be observed with respect to both sense and motion. 
Thus when a person is falling asleep, the sensibility is gra- 
dually diminished : so that, although some degree of sleep 
has come on, slight impressions will excite sensation, and 



480 PRACTICE OF PHYSIC. 

bring back excitement ; which the same, or even stronger 
impressions, will be insufficient to produce when the state 
of sleep has continued longer, and is, as we may say, more 
complete. In like manner, the power of voluntary motion 
is gradually diminished. In some members it fails sooner 
than in others ; and it is sometime before it becomes gene- 
ral and considerable over the whole. 

The same gradual progress may be remarked in a per- 
son's coming out of sleep : the ears in this case are often 
awake before the eyes are opened or see clearly, and the 
senses are often awake before the power of voluntary mo- 
tion is recovered ; and it is curious to observe, that, in 
some cases, sensations may be excited without producing 
the ordinary association of ideas. See Mem. de Berlin, 
1752. 

1548.] From all this, I think it will clearly appear, that 
not only the different states of excitement and collapse can 
take place in different degrees, but that they can take place 
in different parts of the brain, or at least, with respect to 
the different functions, in different degrees. 

As I presume that almost every person has perceived 
the gradual approach of sleeping and waking, I likewise 
suppose every person has observed, that, in such interme- 
diate state of unequal excitement, there almost always oc- 
curs more or less of delirium, or dreaming, if any body 
chooses to call it so. There are in this state false percep- 
tions, false associations, false judgments, and dispropor- 
tionate emotions ; in short, all the circumstances by which 
I have above defined delirium. 

This clearly shows that delirium may depend, and I shalt 
hereafter endeavor to prove that it commonly does depend 
upon some inequality in the excitement of the brain; and 
that both these assertions are founded on this, that, in order 
to the proper exercise of our intellectual functions, the ex- 
citement must be complete, and equal in every part of the 
brain. For though we cannot say that the vestiges of ideas 
are laid up in different parts of the brain, or that they are 
in some measure diffused over the whole, it will follow up- 
on either supposition, that as our reasoning and our intel- 
lectual operations always require the orderly and exact re- 
collection or memory of associated ideas ; so, if any part 
of the brain is not excited, or not excitable, that recollec- 
tion cannot properly take place, while at the same time 



PRACTICE OF PHYSIC. s 48 i 

other parts of the brain, more excited and excitable, may 
give false perceptions, associations, and judgments. 

1549.] It will serve to illustrate this, that the collapse in 
sleep is more or less complete ; or that the sleep, as we com- 
monly speak, is more or less profound ; and therefore, that 
in man)' cases, though sleep takes place to a considerable 
degree, yet certain impressions do still take effect, and ex- 
cite motions, or, if you will, sensations in the brain ; but 
which sensations, upon account of the collapsed state of so 
great a part of the brain, are generally of the delirious kind, 
or dreams, consisting of false perceptions, associations, and 
judgments, that would have been corrected if the brain had 
been entirely excited. 

Every one, I believe, has observed, that the most imper- 
fect sleeps, are those chiefly attended with dreaming ; that 
dreams, therefore, most commonly occur towards morning, 
when the complete state of sleep is passing away ; and fur- 
ther, that dreams are most commonly excited by strong and 
uneasy impressions made upon the body. 

I apprehend it may also be an illustration of the same 
thing, that, even in waking hours, we have an instance of 
an unequal state of excitement in the brain producing deli- 
rium. Such, I think, occurs in the case of fever. In this 
it is manifest, that the energy of the brain, or its excitement, 
is considerably diminished with respect to the animal func- 
tions : and it is accordingly upon this ground that I have 
explained above, in 45, the delirium which so commonly 
attends fever. To what I have there said I shall here only 
add, that it may serve to confirm my doctrine, that the de- 
lirium in fever comes on at a certain period of the disease 
only, and that Ave can commonly discern its approach by a 
more than usual degree of it appearing in the time of the pa- 
tient's falling into or coming out of sleep. It appears, there- 
fore, that delirium, when it first comes on in fever, depends 
upon an inequality of excitement ; and it can hardly be 
doubted, that the delirium which comes at length to prevail 
in the entirely weakened state of fevers, depends upon the 
same cause prevailing in a more considerable degree. 

1550.] From what has been now delivered, I hope it 
will be sufficiently evident, that delirium may be, and fre- 
quently is, occasioned by an inequality in the excitement 
of the brain. 

I low the different portions of the brain may at the same 
time be excited or collapsed in different degrees, or how the 

3Q 



48$ PRACTICE OF PHYSIC. 

energy of the brain may be in different degrees of force, 
with respect to the several animal, vital, and natural func- 
tions, I cannot pretend to explain ; but it is sufficiently 
evident in fact, that the brain may be at one and the same 
time in different conditions with respect to these functions. 
Thus in inflammatory diseases, when by a stimulus applied 
to the brain the force of the vital functions is preternaturally 
increased, that of the animal is either little changed, or con- 
siderably diminished. On the contrary, in many cases of 
mania, the force of the animal functions depending always 
on the brain, is prodigiously increased, while the state of 
the vital function in the heart, is very little or not at all 
changed. I must therefore say again, that how difficult 
soever it may be to explain the mechanical or physical con- 
dition of the brain in such cases, the facts are sufficient to 
show that there is such an inequality as may disturb our in- 
tellectual operations. 

1551.] I have thus endeavored to explain the general 
cause of Delirium ; which is of two kinds, according as it 
is with, or without, pyrexia. Of the first I take no further 
notice here, having explained it as well as I could abov& 
in 45. 

I proceed now to consider that delirium which properly 
belongs to the class of Vesanise, and which I shall treat of 
under the general title of Insanity. 

1552.] In entering upon this subject, it immediately oc- 
curs, that in many instances of insanity, we find, upon 
dissection after death, that peculiar circumstances had taken 
place in the general condition of the brain. In many cases, 
it has been found of a drier, harder, and firmer consistence, 
than what it is usually of in persons who had not been af- 
fected with that disease. In other cases it has been found 
in a more humid, soft, and flaccid state ; and in the ob- 
servations of the late Mr. Meckel,* it has been found con- 
siderably changed in its density or specific gravity. Whe- 
ther these different states have been observed to be uniform- 
ly the same over the whole of the brain, I cannot certainly 
learn ; and I suspect the dissectors have not always accu- 
rately inquired into this circumstance : but in several in- 
stances, it appears that these states had been different in 
different parts of the brain ; and instances of this inequality 
will afford a confirmation of our general doctrine. 

•Memoir de Berlin pour l'annee YiCA. It appeared in many instance? of insane persons, 
that the medullary substance of the cerebrum was drier, and of a less specific gravity, than ir 
persons who had 6een always of a sound judgment. Author. 



PRACTICE OF PHYSIC. 48S 

The accurate Morgagni has observed, that in maniacal 
persons the medullary portion of the brain is usually dry, 
hard, and firm : and this he had so frequently observed, that 
he was disposed to consider it as generally the case. But 
in most of the particular instances which he has given, it 
appears, that, for the most part, while the cerebrum was of 
an unusually hard and firm consistence, the cerebellum was 
of its usual softness, and in many of the cases it was unusu- 
ally soft and flaccid. In some other cases, Morgagni ob- 
serves, that while a part of the cerebrum was harder and 
firmer than ordinary, other parts of it were preternatu rally 
soft. 

1553.] These observations tend to confirm our general 
doctrine : and there are others which I think will apply to 
the same purpose. 

Upon the dissection of the bodies of persons who had la- 
bored under insanity, various organic affections have been 
discovered in particular parts of the brain ; and it is suffi- 
ciently probable, that such organic affections might have 
produced a different degree of excitement in the free and 
affected parts, and must have interrupted in some measure 
the free communication between the several parts of the 
brain, and in either way have occasioned insanity. 

There have occurred so many instances of this kind, that 
I believe physicians are generally disposed to suspect orga- 
nic lesions of the brain to exist in almost every case of 
insanity. 

1554.] This, however, is probably a mistake: for we 
know that there have been many instances of insanity, from 
which the persons have entirely recovered ; and it is difficult 
to suppose that any organic lesions of the brain had in such 
case taken place. Such transitory cases, indeed, render it 
probable, that a state of excitement, changeable by various 
causes, had been the cause of such instances of insanity. 

1555.] It is indeed further asserted, that in many instances 
of insane persons, their brain had been examined after 
death, without showing that any organic lesions had before 
subsisted in the brain, or finding that any morbid state of 
the brain then appeared. This, no doubt, may serve to 
show, that organic lesions had not been the cause of the dis- 
ease ; but it does not assure us that no morbid change had 
taken place in the brain : for it is probable, that the dissec- 
tors were not always aware of its being the general condition 
©f hardness and density, as different in different parts of the 



484 PRACTICE OF PHYSIC. 

brain, that was to be attended to, in order to discover the 
cause of the preceding disease ; and therefore many of 
them had not with this view examined the state of the brain, 
as Morgagni seems carefully to have done. 

1556.] Having thus endeavored to investigate the cause 
of insanity in general, it were to be wished that I could ap- 
ply the doctrine to the distinguishing the several species of 
it, according as they depend upon the different state and 
circumstances of the brain, and thereby to the establishing 
of a scientific and accurately adapted method of cure. 
These purposes, however, appear to me to be extremely 
difficult to be attained ; and I cannot hope to execute them 
here. All I can do is to make some attempts, and offer 
some reflections, which further observation, and greater 
sagacity, may hereafter render more useful. 

1557.] The ingenious Dr. Arnold has been commend- 
ably employed in distinguishing the different species of in- 
sanity as they appear with respect to the mind ; and his la- 
bors may hereafter prove useful, when we shall come to 
know something more of the different states of the brain 
corresponding to these different states of the mind ; but at 
present I can make little application of his numerous dis- 
tinctions. It appears to me that he has chiefly pointed out 
and enumerated distinctions, that are merely varieties, 
which can lead to little or no variety of practice : and I am 
especially led to form the latter conclusion, because these 
varieties appear to me to be often combined together, and 
to be often changed into one another, in the same person; 
in whom we must therefore suppose a general cause of the 
disease, which, so far as it can be known, must establish 
the pathology, and especially direct the practice. 

1558.] In my limited views of the different states of in- 
sanity, I must go on to consider them under the two heads 
of Mania and Melancholia: and though I am sensible that 
these two genera do not comprehend the whole of the spe- 
cies of insanity, I am not clear in assigning the other spe- 
cies which may not be comprehended under those titles. I 
shall, however, endeavor, on proper occasions as I go 
along, to point them out as well as I can. 



PRACTICE OF PHYSIC. 485 



CHAPTER II. 
OF MANIA, OR MADNESS. 

1559.] HPHE circumstances which I have mentioned 
A above in 1536, as constituting delirium in 
general, do more especially belong to that kind or' it which 
I shall treat of here under the title of mania. 

There is sometimes a false perception or imagination of 
things present that are not ; but this is not a constant, nor 
even a frequent, attendant of the disease. The false judg- 
ment, is of relations long before laid up in the memory. 
It very often turns upon one single subject ; but more 
commonly the mind rambles from one subject to another 
with an equally false judgment concerning the most part 
of them ; and as at the same time there is commonly a 
false association, this increases the confusion of ideas, and 
therefore the false judgments. What for the most part 
more especially distinguishes the disease is a hurry of mind, 
in pursuing any thing like a train of thought, and in run- 
ning from one train of thought to another. Maniacal per- 
sons are in general very irascible ; but what more particu- 
larly produces their angry emotions, is, that their false 
judgments lead to some action which is always pushed with 
impetuosity and violence ; when this is interrupted or re- 
strained, they break out into violent anger and furious vio- 
lence against every person near them, and upon every 
thing that stands in the way of their impetuous will. The 
false judgment often turns upon a mistaken opinion of 
some injury supposed to have been formerly received, or 
now supposed to be intended : and it is remarkable, that 
such an opinion is often with respect to then- former dear- 
est friends and relations ; and therefore their resentment 
and anger are particularly directed towards these. And 
although this should not be the case, they commonly soon 
lose that respect and regard which they formerly had for 
their friends and relations. With all these circumstances, 
it will be readily perceived, that the disease must be at- 
tended very constantly with that incoherent and absurd 
speech we call raving. Further, with the circumstances 
mentioned, there is commonly joined an unusual force in all 
the voluntary motions ; and an insensibility or resistance of 
the force of all impressions, and particularly a resistance of 



486 PRACTICE OF PHYSIC, 

the powers of sleep, of cold, and even of hunger ; though 
indeed in many instances a voracious appetite takes place. 

1560.] It appears to me that the whole of these circum- 
stances and symptoms point oat a considerable and unusual 
excess in the excitement of the brain, especially with re- 
spect to the animal functions ; and it appears at the same 
time to be manifestly in some measure unequal, as it very 
often takes place with respect to these functions alone, 
while at the same time the vital and natural are commonly 
very little changed from their ordinary healthy state. 

1561.] How this excess of excitement is produced, it 
may be difficult to explain. In the various instances of 
what Sauvages has named the Mania Metastatica, and in 
all the instances I have mentioned in my Nosology under 
the title of the Mania Corporea, it may be supposed that a 
morbid organic affection is produced in some part of the 
brain : and how that may produce an increased or une- 
qual excitement in certain parts of it, I have endeavored 
to explain above in 1553. But I must at the same time 
acknowledge, that such remote causes of mania have very 
rarely occurred ; and that therefore some other causes of 
the disease must be sought for. 

The effects of violent emotions or passions of the mind 
have more frequently occurred as the remote causes of 
mania ; and it is sufficiently probable, that such violent 
emotions, as they do often immediately produce a tempo- 
rary increase of excitement, so they may, upon some oc- 
casions of their permanent inherence or frequent repetition, 
produce a more considerable and more permanent excite- 
ment, that is, a mania. 

With respect to those causes of mania which arise in 
consequence of a melancholia which had previously long 
subsisted ; whether we consider that melancholia as a par- 
tial insanity, or as a long persisting attachment to one 
train of thinking, it will be readily perceived, that in either 
case, such an increase of excitement may take place in so 
considerable a degree, and in so large a portion of the brain, 
as may give occasion to complete mania. 

1562.] These considerations with regard to the remote 
causes appear to me to confirm sufficiently our general doc- 
trine of increased and unequal excitement in the mania 
which I have described above ; but I must own that I have 
not exhausted the subject, and that there are cases of mania 
of which I cannot assign the remote causes : but although I 



PRACTICE OF PHYSIC. 487 

cannot in all cases explain in what manner the mania is pro- 
duced, I presume, from the explanation given, and espe- 
cially from the symptoms enumerated above, to conclude, 
that the disease described above depends upon an increased 
excitement of the brain ; an opinion in which I am the more 
confirmed, as I think it will point out the proper method of 
cure. At least I think it will most clearly explain the ope- 
ration of those remedies, which, so far as I can learn from 
my own experience and that of others, have proved the most 
successful in this disease ; and, to illustrate this, I now enter 
upon the consideration of these remedies, and to make some 
remarks upon the proper manner of employing them. 

1563.] Restraining the anger and violence of madmen is 
always necessary for preventing their hurting themselves or 
others : but this restraint is also to be considered as a remedy. 
Angry passions are always rendered more violent by the in- 
dulgence of the impetuous motions they produce ; and even 
in madmen the feeling of restraint will sometimes prevent 
the efforts which their passion would otherwise occasion. 
Restraint, therefore, is useful, and ought to be complete; 
but it should be executed in the easiest manner possible for 
the patient, and the strait waistcoat answers every purpose 
better than any other that has yet been thought of. The 
restraining madmen by the force of other men, as occasion- 
ing a constant struggle and violent agitation, is often hurt- 
ful. Although, on many occasions, it may not be safe to 
allow maniacs to be upon their legs or to walk about, it is 
never desirable to confine them to a horizontal situation ; 
and whenever it can be admitted, they should be more or 
less in an erect posture. Although there may be no symp- 
toms of any preternatural fulness or increased impetus of 
blood in the vessels of the brain, a horizontal posture al- 
ways increases the fulness and tension of these vessels, and 
may thereby increase the excitement of the brain. 

1564.] The restraint mentioned requires confinement 
within doors, and it should be in a place which presents as 
few objects of sight and hearing as possible ; and particu- 
larly, it should be removed from the objects that the patient 
was formerly acquainted with, as these would more readily 
call up ideas and their various associations. It is for this 
reason that the confinement of madmen should hardly ever 
be in their usual habitation ; or if they are, that their apart- 
ment should be stripped of all its former furniture. It is 
also lor the most part proper, that maniacs should be with- 



488 PRACTICE OF PHYSIC. 

out the company of any of their former acquaintance ; the 
appearance of whom commonly excites emotions that in- 
crease the disease. Strangers may at first be offensive ; but 
in a little time they come to be objects either of indifference 
or of fear, and they should not be frequently changed. 

1565.] Fear being a passion that diminishes excitement, 
may therefore be opposed to the excess of it ; and particu- 
larly to the angry and irascible excitement of maniacs. 
These being more susceptible of fear than might be suspect- 
ed, it appears to me to have been commonly useful. In 
most cases it has appeared to be necessary to employ a very 
constant impression of fear ; and therefore to inspire them 
with the awe and dread of some particular persons, espe- 
cially of those who are to be constantly near them. This 
awe and dread is therefore, by one means or other, to be 
acquired ; in the first place, by their being the authors of 
all the restraints that may be occasionally proper ; but 
sometimes it may be necessary to acquire it even by stripes 
and blows. The former, although having the appearance 
of more severity, are much safer than strokes or blows 
about the head. Neither of them, however, should be 
employed further than seems very necessary, and should be 
trusted only to those whose discretion can be depended up- 
on. There is one case in which they are superfluous ; that 
is, when the maniacal rage is either not susceptible of fear, 
or incapable! of remembering the objects of it ; for in such 
instances, stripes and blows would be wanton barbarity. In 
many cases of a moderate disease, it is of advantage that 
the persons who are the authors of restraint and punishment, 
should be upon other occasions the bestowers of every in- 
dulgence and gratification that is admissible ; never, how- 
ever, neglecting to employ their awe when their indulgence 
shall have led to any abuse. 

1566.] Although in mania, no particular irritation nor 
fulness of the system seem to be present, it is plain, that the 
avoiding all irritation and means of fulness is proper ; and 
therefore, that a diet neither stimulating nor nourishing is 
commonly to be employed. As it may even be useful to di- 
minish the fulness of the system, so both a low and a spare 
diet is likely in most cases to be of service. 

1567.] Upon the same principle, although no unusual 
fulness of the body be present, it may be of advantage to 
diminish even its ordinary fulness by different evacuations. 

Blood-letting, in particular, might be supposed useful ; 



PRACTICE OF PHYSIC. 4 S9 

and in all recent cases of mania it has been commonly prac- 
tised, and I think with advantage ; but when the disease 
has subsisted for some time, I have seldom found blood-let- 
ting of service. In those instances in which there is any fre- 
quency or fulness of pulse, or any marks of an increased 
impetus of the blood in the vessels of the head, blood-letting 
is a proper and even a necessary remedy. Some practition- 
ers, in such cases, have preferred a particular manner of 
blood-letting, recommending arteriotomy, scarifying the 
hind-head, or opening the jugular vein ; and where any 
fulness or inflammatory disposition in the vessels of the brain 
is to be suspected, the opening of the vessels nearest to them 
is likely to be of the greatest service. The opening, how- 
ever, of either the temporal artery or the jugular vein in 
maniacal persons is very often inconvenient ; and it may ge- 
nerally be sufficient to open a vein in the arm, while the body 
is kept in somewhat of an erect posture, and such a quantity 
of blood drawn as nearly brings on a deliquium animi, 
which is always a pretty certain mark of some diminution 
of the fulness and tension of the vessels of the brain. 

1568.] For the same purpose of taking off the fulness 
and tension of these vessels of the brain, purging may be 
employed ; and I can in no other view understand the ce- 
lebrated use of hellebore among the ancients. I cannot, 
however, suppose any specific power in hellebore ; and 
can by no means find that, at least the black hellebore, is 
so efficacious with us as it is said to have been at Anticyra. 
As costiveness, however, is commonly a very constant and 
hurtful attendant of mania, purgatives come to be some- 
times very necessary ; and I have known some benefit ob- 
tained from the frequent use of pretty drastic purgatives. 
In this, however, 1 have been frequently disappointed ; 
and I have found more advantage from the frequent use of 
cooling purgatives, particularly the soluble tartar, than 
from more drastic medicines. 

1569.] Vomiting has also been frequently employed in 
mania; and by determining powerfully to the surface of the 
body, it may possibly diminish the fulness and tension of 
the vessels, and thereby the excitement of the brain ; but 
I have never carried the use of this remedy so far as might 
enable me to judge properly of its effects. Whether it 
may do harm by impelling the blood too forcibly into the 
vessels of the brain, or whether by its general agitation of 
the whole svstcm it may remove that inequality of excite- 

3a 



490 PRACTICE OF PHYSIC. 

ment which prevails in mania, I have not had experience 
enough to determine. 

1570.] Frequent shaving of the head has been found of 
service in mania, and by promoting perspiration it probably 
takes off from the excitement of the internal parts. This, 
however, it is likely, may be more effectually done by 
blistering, which more certainly takes off the excitement 
of subjacent parts. In recent cases it has been found use- 
ful by inducing sleep ; and when it has that effect, the re- 
petition of it may be proper : but in maniacal cases that 
have lasted for some time, blistering has not appeared to 
me to be of any service ; and in such cases also I have not 
found perpetual blisters, or any other form of issue, prove 
useful. 

1571.] As heat is the principal means of first exciting 
the nervous system, and establishing the nervous power 
and vital principle in animals ; so, in cases of preternatural 
excitement, the application of cold might be supposed a 
proper remedy : but there are many instances of maniacs 
who have been exposed for a great length of time to a con- 
siderable degree of cold without having their symptoms 
anywise relieved. This may render in general the appli- 
cation of cold a doubtful remedy ; but it is at the same 
time certain, that maniacs have often been relieved, and 
sometimes entirely cured, by the use of cold bathing, es- 
pecially when administered in a certain manner. This 
seems to consist, in throwing the madman in the cold wa- 
ter by surprise ; by detaining him in it for some length of 
time; and pouring water frequently upon the head, while 
the whole of the body except the head is immersed in the 
water ; and thus managing the whole process, so as that, 
with the assistance of some fear, a refrigerant effect may 
be produced. This, I can affirm, has been often useful ; 
and that the external application of cold may be of service, 
we know further from the benefit which has been received 
in some maniacal cases from the application of ice and 
snow to the naked head, and from the application of the 
noted Clay Clap. 

Warm bathing also has been recommended by some 
practical writers ; and in some rigid melancholic habits it 
may possibly be useful, or as employed in the manner pre- 
scribed by some, of immersing the lower parts of the body 
in warm water, while cold water is poured upon the head 
and upper parts. Of this practice, however, I have had no 



PRACTICE OF PHYSIC. 491 

experience, and in the common manner of employing warm 
bathing I have found it rather hurtful to maniacs. 

1 572.] According to my supposition that the disease de- 
pends upon an increased excitement of the brain, especi- 
ally with respect to the animal functions, opium, so com- 
monly powerful in inducing sleep, or a considerable col- 
lapse as to these functions, should be a powerful remedy 
of mania. That it has truly proved such, I believe from 
the testimony of Bernard Huet, whose practice is narrated 
at the end of Wepferi Historia Apoplecticorum. I leave 
to my readers to study this in the work I have referred to, 
where every part of the practice is fully, and it appears 
to me, very judiciously delivered. I have never indeed 
carried the trial so far as seems to be requisite to an entire 
cure : but 1 have frequently employed in some maniacal 
cases large doses of opium ; and when they had the effect 
of inducing sleep, it was manifestly with advantage. At 
the same time, in some cases, from doubts, whether the 
disease might not depend upon some organic lesions of the 
brain, when the opium would be superfluous ; and in other 
cases, from doubts, whether there might not be some in- 
flammatory affection joined with the mania, when the opi- 
um would be hurtful, I have never pushed this remedy to 
the extent that might be necessary to make an entire cure. 

1573.] Camphire has been recommended as a remedy 
of mania, and there are instances allcdged of its having 
performed an entire cure. As it appears from the expe- 
riments of Beccaria that this substance is possessed of a se- 
dative and narcotic virtue, these cures are not altogether 
improbable : but in several trials, and even in large doses, 
I have found no benefit from it ; and excepting those in the 
Philosophical Transactions, No. 400. I have hardly met 
with any other testimonies in its favor. 

1574.] I have been informed that some maniacs have 
been cured by being compelled to constant and even hard 
labor ; and as a forced attention to the conduct of any bo- 
dily exercise is a very certain means of diverting the mind 
from pursuing any train of thought, it is highly probable 
that such exercise may be useful in many cases of mania. 

I must conclude this subject with observing, that even 
in several cases of complete mania, I have known a cure 
take place in the course of a journey carried on for some 
length of time. 

1575]. These arc the remedies which have been chiefly 



492 PRACTICE OF PHYSIC. 

employed in the mania that has been above described, and 
I believe they have been employed promiscuously without 
supposing that the mania was to be distinguished into dif- 
ferent species. Indeed I am not ready to say how far it is 
to be so distinguished, but I shall offer one observation 
which may possibly merit attention. 

It appears to me that there are two different cases of ma- 
nia that are especially different according to the original 
temperament of the persons whom the disease affects. It 
perhaps occurs most frequently in persons of a melancho- 
lic or atrabilarian temperament ; but it certainly does also 
often occur in persons of that very opposite temperament 
w r hich physicians have named the Sanguine. According as 
the disease happens to occur in persons of the one or other 
of these temperaments, I apprehend it may be considered 
as of a different nature ; and I believe, that accurate ob- 
servation, employed upon a sufficient number of cases, 
would discern some pretty constant difference, either of 
the symptoms, or at least of the state of the symptoms, in 
the two cases. I imagine that false imaginations, particular 
aversions and resentments, are more fixed and steady in 
the melancholic than in the sanguine ; and that somewhat 
inflammatory is more commonly joined with mania in the 
sanguine than in the melancholic. If such difference, how- 
ever, does truly take place, it will be obvious, that it may 
be proper to make some difference also in the practice. I 
am of opinion, that in the mania of sanguine persons, blood- 
Jetting and other antiphlogistic measures are more proper, 
and have been more useful, than in the melancholic. I 
likewise apprehend that cold bathing is more useful in the 
sanguine than in the melancholic : but I have not had ex- 
perience enough to ascertain these points with sufficient 
confidence. 

1 have only to add to this other observation, that mani- 
acs of the sanguine temperament recover more frequently 
and more entirely than those of the melancholic. 



CHAPTER III. 

OF MELANCHOLY AND OTHER FORMS OF 
INSANITY. 

1576.] TV MELANCHOLY has been commonly consi- 
IV X. dered as partial insanity ; and as such it is 



PRACTICE OF PHYSIC. 493 

defined in my Nosology : but I now entertain doubts if 
this be altogether proper. By a partial insanity, I under- 
stand a false and mistaken judgment upon one particular 
subject, and what relates to it ; whilst, on every other sub- 
ject, the person affected judges as the generality of other 
men do. Such cases have certainly occurred ; but, I be- 
lieve, few in which the partial insanity is strictly limited. 
In many cases of general insanity, there is one subject of 
anger or fear, upon which the false judgment more parti- 
cularly turns, or which is at least more frequently than any 
other the prevailing object of delirium : and though, from 
the inconsistency which this principal object of delirium 
must produce, there is therefore also a great deal of insa- 
nity with regard to most other objects ; yet this last is in 
very different degrees, both in different persons, and in the 
same person at different times. Thus persons considered 
as generally insane, will, however, at times, and in some 
cases, pretty constantly judge properly enough of present 
circumstances and incidental occurrences ; though, when 
these objects engaging attention are not presented, the ope- 
rations of imagination may readily bring back a general 
confusion, or recal the particular object of the delirium. 
From these considerations, I am inclined to conclude, that 
the limits between general and partial insanity cannot al- 
ways be so exactly assigned, as to determine when the par- 
tial affection is to be considered as giving a peculiar spe- 
cies of disease, different from a more general insanity. 

1577.] When insanity, neither strictly partial nor en- 
tirely nor constantly general, occurs in persons of a san- 
guine temperament, and is attended with agreeable, rather 
than with angry or gloomy emotions, I think such a disease 
must be considered as different from the Mania described 
above; and also, though partial, must be held as different 
from the proper Melancholia to be mentioned hereafter. 

1578.] Such a disease, as different from those described 
(1555.) requires, in my opinion, a different administration 
of remedies ; and it will be proper for me to take particu- 
lar notice of this here. 

Although it may be necessary to restrain such insane 
persons as we have mentioned (1577.) from pursuing the 
objects of their false imagination or judgment, it will hard- 
ly be requisite to employ the same force of restraint that is 
necessary in the impetuous and angry mania. It will be ge- 
nerally sufficient to acquire some awe over them, ihat may 



434 PRACTICE OF PHYSIC. 

be employed, and sometimes even be necessary, to check 
the rambling of their imagination, and incoherency of 
judgment. 

1579.] The restraint just now mentioned as necessary 
will generally require the patient's being confined to one 
place, for the sake of excluding the objects, and more 
particularly the persons, that might excite ideas connect- 
ed with the chief objects of their delirium. At the same 
time, however, if it can be perceived there are objects or 
persons that can call off their attention from the pursuit of 
their own disordered imagination, and fix it a little upon 
some others, these last may be frequently presented to them : 
and for this reason, a journey, both by its having the effect 
of interrupting all train of thought, and by presenting ob- 
jects engaging attention, may often be useful. In such ca- 
ses also, when the insanity, though more especially fixed 
upon one mistaken subject, is not confined to this alone, 
but is further apt to ramble over other subjects with inco- 
herent ideas, I apprehend the confining or forcing such 
persons to some constant uniform labor, may prove an 
useful remedy. 

1580.] When such cases as in 1577, occur in sanguine 
temperaments, and may therefore approach more nearly to 
Phrenitic Delirium ; so, in proportion as the symptoms of 
this tendency are more evident and considerable, blood- 
letting and purging will be the more proper and necessary. 

1581.] To this species of insanity, when occurring in 
sanguine temperaments, whether it be more or less partial, 
I apprehend that cold bathing is particularly adapted ; 
while hi the partial insanity of melancholic persons, as I 
shall show hereafter, it is hardly admissible. 

1582.] Having thus treated of a species of insanity, dif- 
ferent in my apprehension, from both the Mania and Me- 
lancholia, I proceed to consider what seems more proper- 
ly to belong to this last. 

1583.] The disease which I name Melancholia is very 
often a partial insanity only. But as in many instances, 
though the false imagination or judgment seems to be with 
respect to one subject only ; yet it seldom happens that 
this does not produce much inconsistency in the other in- 
tellectual operations : and as, between a very general and 
a very partial insanity, there are all the possible interme- 
diate degrees ; so it will be often difficult, or perhaps im- 
proper, to distinguish melancholia by the character of Par- 



PRACTICE OF PHYSIC. 495 

tial Insanity alone. If I mistake not, it must be chiefly 
distinguished by its occurring in persons of a melancholic 
temperament, and by its being always attended with some 
seemingly groundless, but very anxious fear. 

15S4.] To explain the cause of this, I must observe, 
that persons of a melancholic temperament are for the 
most part of a serious, thoughtful disposition, and disposed 
to fear and caution, rather than to hope and temerity. 
Persons of this cast are less moveable than others by any 
impressions : and are therefore capable of a closer or more 
Continued attention to one particular object, or train of 
thinking. They are even ready to be engaged in a con- 
stant application to one subject ; and are remarkably tena- 
cious of whatever emotions they happen to be affected with. 

1585.] These circumstances of the melancholic charac- 
ter, seem clearly to shew, that persons strongly affected 
with it may be readily seized with an anxious fear ; and 
that this, when much indulged, as is natural to such per- 
sons, may easily grow into a partial insanity. 

1586.] Fear and dejection of mind, or a timid and de- 
sponding disposition, may arise in certain states, or upon 
certain occasions of mere debility : and it is upon this foot- 
ing, that I suppose it sometimes to attend dyspepsia. But 
in these cases, I believe the despondent disposition hardly 
ever arises to a considerable degree, or proves so obstinate- 
ly fixed as when it occurs in persons of a melancholic tem- 
perament. In these last, although the fear proceeds from 
the same dyspeptic feelings as in the other case, yet it will 
be obvious, that the emotion may rise to a more conside- 
rable degree ; that it may be more anxious, more fixed, 
and more attentive ; and therefore may exhibit all the va- 
rious circumstances which I have mentioned in 1222, to 
take place in the disease named hypochondriasis. 

1587.] In considering this subject formerly in distin- 
guishing Dyspepsia from Hypochondriasis, although the 
symptoms affecting the body be very much the same in 
both, and even those affecting the mind be somewhat simi- 
lar, I found no difficulty in distinguishing the latter dis- 
ease, merely from its occurring in persons of a melancho- 
lic temperament. But I must now acknowledge, that I am 
at a loss to determine how in all cases hypochondriasis and 
melancholia may be distinguished from one another, whilst 
the same temperament is common to both. 



496 PRACTICE OF PHYSIC. 

1588.] I apprehend, however, that the distinction may 
be generally ascertained in the following manner. 

The hypochondriasis I would consider as being always 
attended with dyspeptic symptoms : and though there may 
be, at the same time, an anxious melancholic fear arising 
from the feeling of these symptoms ; yet while this fear is 
only a mistaken judgment with respect to the state of the 
person's own health, and to the danger to be from thence 
apprehended, I would still consider the disease as a hypo- 
chondriasis, and as distinct from the proper melancholia. 
But when an anxious fear and despondency arises from a 
mistakenjudgment with respect to other circumstances than 
those of health, and more especially when the person is at 
the same time without any dyspeptic symptoms, every one 
will readily allow this to be a disease widely different from 
both dyspepsia and hypochondriasis ; and it is, what I 
would strictly name Melancholia. 

1589.] In this there seems little difficulty ; but as an ex- 
quisitely melancholic temperament may induce a torpor 
and slowness in the action of the stomach, so it generally 
produces some dyspeptic symptoms : and from thence there 
may be some difficulty in distinguishing such a case from 
hypochondriasis. But I would maintain, however, that 
when the characters of the temperament are strongly mark- 
ed ; and more particularly when the false imagination turns 
upon other subjects than that of health, or when, though 
relative to the person's own body, it is of a groundless and 
absurd kind ; then, notwithstanding the appearance of 
some dyspeptic symptoms, the case is still to be consider- 
ed as that of a melancholia, rather than a hypochondriasis. 

1590.] The disease of melancholia, therefore manifestly 
depends upon the general temperament of the body : and 
although, in man)' persons, this temperament is not attend- 
ed with any morbid affection either of mind or body ; yet 
when it becomes exquisitely formed, and is in a high de- 
gree, it may become a disease affecting both, and particu- 
larly the mind. It will therefore be proper to consider in 
what this melancholic temperament especially consists ; and 
to this purpose, it may be observed, that in it there is a de- 
gree of torpor in the motion of the nervous power, both 
with respect to sensation and volition ; that there is a gene- 
ral rigidity of the simple solids ; and that the balance of 
the sanguiferous system, is upon the side of the veins. But 
ail these circumstances are the directly opposite of those of 



PRACTICE OF PHYSIC. 497 

the sanguine temperament ; and must therefore also pro- 
duce an opposite state of the mind. 

1591. J It is this state of the mind, and the state of the 
brain corresponding to it, that is the chief object of our pre- 
sent consideration. But what that state of the brain is, will 
be supposed to be difficult to explain} and it may perhaps 
seem rash in me to attempt it. 

I will, however, venture to say, that it is probable the 
melancholic temperament of mind depends upon a drier and 
firmer texture in the medullary substance of the brain ; and 
that this perhaps proceeds from a certain want of fluid in 
that substance, which appears from its being of a lesser spe- 
cific gravity than usual. That this state of the brain in 
melancholia does actually exist, I conclude, firsts from the 
general rigidity of the whole habit ; and, secondly, from dis- 
sections, showing such a state of the brain to have taken 
place in mania, which is often no other than a higher degree 
of melancholia. It does not appear to me any wise difficult 
to suppose, that the same state of the brain may in a mo- 
derate degree give melancholia ; and in a higher, that mania 
which melancholia so often passes into ; especially if 1 shall 
be allowed further to suppose, that either a greater degree 
of firmness in the substance of the brain may render it sus- 
ceptible of a higher degree of excitement, or that one por- 
tion of the brain may be liable to acquire a greater firm- 
ness than others, and consequently give occasion to that ine- 
quality of excitement upon which mania so much depends. 

1592.] I have thus endeavored to deliver what appears 
to me most probable with respect to the proximate cause 
of melancholia ; and although the matter should in some 
respects remain doubtful, I am well persuaded that these 
observations may be often employed to direct our practice 
in this disease, as I shall now endeavor to show. 

1593.] In most of the instances of melancholia, the mind 
is to be managed very much in the same manner as I have 
advised above with regard to hypochondriasis ; but as in 
the case of proper melancholia, tnere is commonly a false 
imagination or judgment appearing as a partial insanity, it 
may be further necessary in such cases to employ some ar- 
tifices for correcting such imagination or judgment. 

1594.] The various remedies for relieving the dyspeptic 
symptoms which always attend hypochondriasis, will seldom 
be either requisite or proper in melancholia. 

There is only one of the dyspeptic symptoms, which, 

3s 



498 PRACTICE OF PHYSIC. 

though there should be no other, is very constantly present 
in melancholia, and that is costiveness. This it is always 
proper and even necessary to remove ; and I believe it is 
upon this account that the use of purgatives has been found 
so often useful in melancholia. Whether there be any pur- 
gatives peculiarly proper in this case, I dare not positively 
determine ; but with respect to the choice of purgatives in 
melancholia, I am of the same opinion that I delivered above 
on this same subject with respect to mania. 

1595.] With respect to other remedies, I judge that blood- 
letting will more seldom be proper in melancholia than in 
mania ; but how far it may be in any case proper, must be 
determined by the same considerations as in the case of mania. 

1596.] The cold bathing that I judged to be so very use- 
ful in several cases of insanity, is, I believe, in melancholia, 
hardly ever fit to be admitted ; at least while this is purely 
a partial affection, and without any marks of violent excite- 
ment. On the contrary, upon account of the general rigi- 
dity prevailing in melancholia, it is probable that warm 
bathing may be often useful. 

1597.] With respect to opiates which I have supposed 
might often be useful in cases of mania, I believe they can 
seldom be properly employed in the partial insanities of the 
melancholic, except in certain instances of violent excite- 
ment, when the melancholia approaches nearly to the state 
of mania. 

1 598.] In such cases of melancholia approaching to a state 
of mania, a low diet may sometimes be necessary ; but as 
the employing a low diet almost unavoidably leads to the use 
of vegetable food, and as this in every torpid state of the 
stomach is ready to produce some dyspeptic symptoms, 
such vegetable food ought, in moderate cases of melancho- 
lia, to be used with some caution. 

Though exercise, as a tonic power, is not proper either 
in hypochondriasis or melancholia ; yet, with respect to its 
effects upon the mind, it may be extremely useful in both, 
and in melancholia is to be employed in the same manner 
that I have advised above in the case of hypochondriasis. 

1599.] Having now delivered my doctrine with respect 
to the forms of insanity, I should in the next place proceed 
to consider the other genera of Amentia and Oneirodynia, 
which in the Nosology I have arranged under the order of 
Vesaniae ; but as I cannot pretend to throw much light up- 
on these subjects, and as they are seldom the objects of 



PRACTICE OF PHYSIC. 499 

practice, I think it allowable for me to pass them over at 
present ; and the particular circumstances of this work iu 
some measure require that I should do so. 



PART III. 

OF CACHEXIES. 

1600.] IT TNDER this title I propose to establish a class 

KJ of diseases, which consist in a depraved state 

of the whole, or of a considerable part, of the habit of the 

body, without any primary pyrexia or neurosis combined 

with that state. 

1601.] The term Cachexy has been employed by Lin- 
naeus and Vogel, as it had been formerly by other authors, 
for the name of a particular disease ; but the disease to which 
these authors have affixed it, comes more properly under 
another appellation ; and the term of Cachexy is more pro- 
perly employed by Sauvages and Sagar for the name of a 
class. In this I have followed the last mentioned nosolo- 
gists, though I find it difficult to give such a character of the 
class as will clearly apply to all the species I have compre- 
hended under it. This difficulty would be still greater, if, 
in the class I have established under the title of Cachexies, 
I were to comprehend all the diseases that those other no- 
sologists have done ; but I am willing to be thought defi- 
cient rather than very incorrect. Those difficulties, how- 
ever, which still remain in methodical nosology, mast not 
affect us much in a treatise of practice. If I can here pro- 
perly distinguish and describe the several species that truly 
and most commonly exist, I shall be the less concerned 
about the accuracy of my general classification ; though at 
the same time this, I think, is always to be attempted ; and 
I shall pursue it as well as I can. 



BOOK I. 

OF EMACIATIONS. 

1602.] T^ MACIATION, or a considerable diminution 
X_j of the bulk or plumpness of the whole body, 



500 PRACTICE OF PHYSIC. 

is for the most part only a symptom of disease, and very sel- 
dom to be considered as a primary and idiopathic affection. 
Upon this account, according to my general plan, such a 
symptom might perhaps have been omitted in the Methodi- 
cal Nosology : but both the uncertainty of concluding it to 
be always symptomatic, and the consistency of system, made 
me introduce into the Nosology, as others had done, an or- 
der under the title of Marcores ; and this renders it requisite 
now to take some notice of such diseases. 

1603.] Upon this occasion, therefore, I hope it may be 
useful to investigate the several causes of emaciation in all 
the different cases of disease in which it appears. And this 
I attempt, as the surest means of determining how far it is a 
primary, or a symptomatic affection only ; and even in the 
latter view, the investigation may be attended with some 
advantage. 

1604.] The causes of emaciation may, I apprehend, be 
referred to two general heads ; that is, either to a general 
deficiency of fluid in the vessels of the body, or to the par- 
ticular deficiency of the oil in the cellular texture of it.* 
These causes are frequently combined together ; but it will 
be proper, in the first place, to consider them separately. 

1605.] As a great part of the body of animals is made 
up of vessels filled with fluids, thebuik of the whole must 
depend very much on the size of these vessels, and the quan- 
tity of fluids present in them: and it will therefore be suf- 
ficiently obvious, that a deficiency of the fluids in these 
vessels must, according to its degree, occasion a proportion- 
ate diminution of the bulk of the whole body. This, how- 
ever, will appear still more clearly, from considering that 
in the living and sound body the vessels every where seem 
to be preternaturally distended by the quantity of fluids 
present in them ; but being at the same time elastic, and 
constantly endeavoring to contract themselves, they must 
on the withdrawing of the distending force, or in other 
words, upon a diminution of the quantity of fluids, be in 
proportion contracted and diminished in their size. And it 
may be further observed, that as each part of the vascular 
system communicates with every other part of it ; so every 
degree of diminution of the quantity of fluid, in any one 
part, must in proportion diminish the bulk of the vascular 
system, and consequently of the whole body. f 

* Might not a third cause be added, viz. a deficiency of the solid parts f 
+ There may, however, be a partial without a general emaciation, as is the case in a palsied 
limb: but this partial diminution of bulk in the diseased limb is not owing to a lessened quau- 



PRACTICE OF PHYSIC. 50t 

1606.] The diminution and deficiency of the fluids mar 
be occasioned by different causes : such as, first, by a due 
quantity of aliments not being taken in ; or by the aliment 
taken in not being of a sufficiently nutritious quality. Of 
the want of a due quantity of aliment not being taken into 
the -body, there is an instance in the atrophia lactantium 
Sauvagesii, species 3. and many other examples have oc- 
curred of emaciation from want of food, occasioned by po- 
verty, and other accidental causes. 

With respect to the quality of food, I apprehend it arises 
from the want of nutritious matter in the food employed, 
that persons living entirely on vegetables are seldom of a 
plump and succulent habit.* 

1607.] A second cause of the deficiency of fluids may 
be, the aliments taken in not being conveyed to the blood- 
vessels. This may occur from a person's being affected 
with a frequent vomiting ; which, rejecting the food soon 
after it had been tak^n in, must prevent the necessary sup- 
ply of fluids to the blood-vessels. f Another cause, fre- 
quently interrupting the conveyance of the alimentary mat- 
ter into the blood-vessels, is an obstruction of the conglo- 
bate or lymphatic glands of the mesentery, through which 
the chyle must necessarily pass to the thoracic duct. Many 
instances of emaciation, seemingly depending upon this 
cause, have been observed by physicians, in persons of all 
ages, but especially in the young. It has also been remark- 
ed, that such cases have most frequently occurred in scro- 
phulous persons, in whom the mesenteric glands are com- 
monly affected with tumor or obstruction, and in whom, 
generally at the same time, scrophula appears externally. 
Hence the Tabes scropJmlosa Si/nop. Nosolog. vol. ii. p. 266. 
And under these I have put as synonimes Tabes glandularis, 
sp. 10. Tabes mesenterica, sp. 9. Scrophula mesenterica , 
sp. 4. Atrophia infantilis, sp. 13. Atrophia rachitica, 
sp. 8. Tabes rachialgica, sp. 16. At the same time, I have 
frequently found the case occurring in persons who did not 
show any external appearance of scrophula, but in whom 

tity of the general mass of the circulating fluids, but to the languid circulation in that part, 
the arteries not propelling the blood through it with sufficient vigor. 

* As the author says at the conclusion of this chapter, " After having considered the various 
causes of emaciations, I should perhaps ycat of their cure: but it will readily appear, that the 
greater part of the cases above mentioned are purely symptomatic, and consequently that the 
cure of them must be that of the primary diseases upon which they depend. Of those cases 
that can anywise be considered as idiopathic, it will appear that they are to be cured entirely 
by removing the remote causes ;" it may not be improper to treat of the care as we proceed. 

This species of emaciation may be obviously cured by a rich and nutritious diet. 

■f This species may be cured by preventing the vomiting by antispasmodics, especially opium, 
and by the use of gentle laxatives occasionally. A nutritious diet will also be necessary in these 
cases. 



502 PRACTICE OF PHYSIC. 

the mesenteric obstruction was afterwards discovered by dis- 
section. Such also I suppose to have been the case in the 
disease frequently mentioned by authors under the title of 
the Atrophia infantum. This has received its name from 
the time of life at which it generally appears ; but I have 
met with instances of it at fourteen years of age ascertained 
by dissection. In several such cases which I have seen, the 
patients were without any scrophulous appearances at the 
time, or at any period of their lives before.* 

In the case of phthisical persons, I shall hereafter men- 
tion another cause of their emaciation ; but it is probable 
tiiat an obstruction of the mesenteric glands, which so fre- 
quently happens in such persons, concurs very powerfully 
in producing the emaciation that takes place. 

Although a scrophulous taint may be the most frequent 
cause of mesenteric obstructions, it is sufficiently probable 
that other kinds of acrimony may produce the same, and 
the emaciation that follows. 

It may perhaps be supposed, that the interruption of the 
chyle's passing into the blood-vessels may be sometimes ow- 
ing to a fault of the absorbents on the internal surface of 
the intestines. This, however, cannot be readily ascer- 
tained : but the interruption of the chyle's passing into the 
blood-vessels may certainly be owing to a rupture of the 
thoracic duct ; which, when it does not prove soon fatal, 
by occasioning a hydrothorax must in a short time produce 
a general emaciation. f 

1608.] A third cause of the deficiency of the fluids may- 
be a fault in the organs of digestion, as not duly converting 
the aliment into a chyle fit to form in the blood-vessels a 
proper nutritious matter. It is not, however, easy to as- 
certain the cases of emaciation which are to be attributed to 
this cause ; but I apprehend that the emaciation which at- 
tends long subsisting cases of dyspepsia, or of hypochon- 
driasis, is to be explained chiefly in this way. It is this 
which I have placed in the Nosology under the title of the 
Atrophia deb ilium ; and of which the Atrophia Nervosa, 
Sauv. sp. 1. is a proper instance, and therefore put there as 
a synonime. But the other titles of Atrophia Lateralis, 
Sauv. sp. 15. and Atrophia senilis, Sauv. sp. 11. are not so 

•These cases are generally incurable; if, however, there be no suspicion of scrophula, we 
may attempt a cure by endeavoring to remove the obstruction either by invigorating the habit, 
or by active aperients. Open and pure air, with exercise suited to the strength of the patient, 
the use of chalybeate waters, have admirable effects in these cases. Peruvian bark so often 
used as a tonic, is improper in all cases of obstructed glands, at are also astringents and sty puci, 

+ This is an absolutely incurable case. 



PRACTICE OF PHYSIC. 503 

properly put there, as they must be explained in a different 
manner.* 

1609.] A fourth cause of a deficiency of the fluids in the 
body, may be excessive evacuations made from it by differ- 
ent outlets ; and Sauvages has properly enumerated the fol- 
lowing species, which we have put as synonimes under the 
title of Atrophia, inanitorum ; as, Tabes nutricum, sp. 4 ; 
Atrophia 7iutricum, sp. 5 ; Atrophia a leueorrhcea, sp. 4 ; 
Atrophia ab alvi fluxu, sp. 6 ; Atrophia a ptyalismo, sp. 7 ; 
and lastly, the Tabes a sanguifluxu ; which, it is to be ob- 
served, may arise not only from spontaneous hemorrhagies 
or accidental wounds, but also from blood-letting in too 
large a quantity, and too frequently repeated. 

Upon this subject it seems proper to observe, that a mea- 
gre habit of body frequently depends upon a full perspiration 
being constantly kept up, though at the same time a large 
quantity of nutritious aliment is regularly taken in.f 

1610.] Besides this deficiency of fluids from evacuations 
by which they are carried entirely out of the body, there 
may be a deficiency of fluid and emaciation in a consider- 
able part of the body, by the fluids being drawn into one 
part, or collected into one cavity ; and of this we have an 
instance in the Tabes a hydrope, Sauv. sp. 5. J 

1611.] In the Methodical Nosology, among the other 
synonimes of the Atrophia inanitorum I have bet down the 
Tabes dorsalis ; but whether properly or not, I at present 
very much doubt. In the evacuation considered as the 
cause of this tabes, as the quantity evacuated is never so 
great as to account for a general deficiency of fluids in the 
body, we must seek for another explanation of it. And 
whether the effects of the evacuation may be accounted for, 
either from the quality of the fluid evacuated, or from the 
singularly enervating pleasure attending the evacuation, or 
from the evacuation's taking off the tension of parts, the 
tension of which has a singular power in supporting the ten- 
sion and vigor of the whole body, I cannot positively de- 
termine ; but I apprehend that upon one or other of these 
suppositions the emaciation attending the tabes dorsalis 
must be accounted for ; and therefore, that it is to be con- 

* This species of emaciation mar be successfully cured by the means of those remedies men- 
tioned in the notes on the articles i204. 1206. l'<!10.' 1212. 1213 1213. 1216. 1821. 

+ In these cases astringents arc the- principal remedies on which we must depend; and those 
astringents must be chosen which are adapted to suppress the peculiar evacuation that occa- 
sions the disease. 

t The emaciation from this cause is merely symptomatic, and can only be cured bycurin» 
the primary dtiea :e. 



504 PRACTICE OF PHYSIC. 

sidered as an instance of the Atrophia debilium, rather than 
of the Atrophia inanitormn.* 

1612.] A fifth cause of a deficiency of fluids and of ema- 
ciations in the whole or in a particular part of the body, 
may be the concretion of the small vessels, either not ad- 
mitting of fluids, or of the same proportion as before ; and 
this seems to me to be the case in the Atrophia senilis, Sauv. 
sp. 2. Or it may be a palsy of the larger trunks of the ar- 
teries rendering them unfit to propel the blood into the small- 
er vessels ; as is frequently the case of paralytic limbs, in 
which the arteries are affected as well as the muscles. The 
Atrophia lateralis, Sauv. sp. 15, seems to be of this 
nature, f 

1613.] A second general head of the causes of emacia- 
tion I have mentioned in 1603, to be a deficiency of oil. 
The extent and quantity of the cellular texture in every 
part of the body, and therefore how considerable a part it 
makes in the bulk of the whole is now well known. But 
this substance, in different circumstances, is more or less 
filled with an oily matter ; and therefore the bulk of it, and 
in a great measure that of the whole body, must be great- 
er or less according as this substance is more or less filled in 
that manner. The deficiency of fluids, for a reason to be 
immediately explained, is generally accompanied with a de- 
ficiency of oil : but physicians have commonly attended 
more to the latter cause of emaciation than to the other, 
that being usually the most evident ; and I shall now endea- 
vor to assign the several causes of the deficiency of oil as it 
occurs upon different occasions. 

1614.] The business of secretion in the human body is in 
general little understood, and in no instance less so than in 
that of the secretion of oil from blood which does not ap- 
pear previously to have contained it. It is possible, there- 
fore, that our theory of the deficiency of oil may be in se- 
veral respects imperfect ; but there are certain facts that 
may in the mean time apply to the present purpose. 

1615.] First, it is probable, that a deficiency of oil may 
be owing to a state of the blood in animal bodies less fitted 
to afford a secretion of oil, and consequently to supply the 
waste of it that is constantly made. This state of the blood 
must especially depend upon the state of the aliments taken 

* If a particular abominable practice be the cause, it must be abandoned before a cure can 
be attempted. 

+ This is one of the incurable speaies of emaciation, and it can only be relieved by a very 
nutritious and invigorating diet. 



PRACTICE OF PHYSIC. 505 

in, as containing less of oil or oily matter. From many 
observations made, both with respect to the human body 
and to that of other animals, it appears pretty clearly, that 
the aliments taken in by men and domestic animals, accord- 
ing as they contain more of oil, are in general more nutri- 
tious, and in particular are better fitted to fill the cellular 
texture of their bodies with oil. I might illustrate this, by 
a minute and particular consideration of the difference of 
alimentary matters employed ; but it will be enough to 
give two instances. The one is, that the herbaceous part of 
vegetables does not fatten animals, so much as the seeds of 
vegetables, which manifestly contain in any given weight a 
greater proportion of oil : and a second instance is, that in 
general vegetable aliments do not fatten men so much as 
animal food, which generally contains a larger portion of oil. 

It will be obvious, that upon the same principles a want 
of food, or a less nutritious food, may not only occasion a 
general deficiency of fluids (1605.) but must also afford less 
oil, to be poured into the cellular texture. In such cases, 
therefore, the emaciation produced, is to be attributed to 
both these general causes.* 

1616.] A second case of the deficiency of oil may be ex- 
plained in this manner. It is pretty manifest, that the oil 
of the blood is secreted and deposited in the cellular tex- 
ture in greater or lesser quantity, according as the circula- 
tion of the blood is faster or slower ; and therefore that ex- 
ercise, which hastens the circulation of the blood, is a fre- 
quent cause of emaciation. Exercise produces this effect 
in two ways. 1st. By increasing the perspiration, and 
thereby carrying off a greater quantity of the nutritious 
matter, it leaves less of it to be deposited in the cellular 
texture ; thereby not only preventing an accumulation of 
fluids, but, as I have said above, causing a general defi- 
ciency of these, which must also cause a deficiency of oil 
in the cellular texture. 2dly, It is well known, that the 
oil deposited in the cellular texture is upon many occasions, 
and for various purposes of the economy, again absorbed, 
and mixed or diffused in the mass of blood, to be from 
thence perhaps carried entirely out of the body by the se- 
veral excretions. Now, among other purposes of the ac- 
cumulation and reabsorption of oil, this seems to be one, 
that the oil is requisite to the proper action of the moving 
fibres in every part of the body ; and therefore that nature 

* The cure of this species of emaciation will be best effected by a rich diet of animal food. 

3t 



506 PRACTICE OF PHYSIC. 

has provided for an absorption of oil to be made according 
as the action of the moving fibres may demand it. It will 
thus be obvious, that the exercise of the muscular and 
moving fibres every where, must occasion an absorption 
of oil ; and consequently that such exercise not only pre- 
vents the secretion of oil, as has been already said, but 
may also cause a deficiency of it, by occasioning an ab- 
sorption of what had been deposited ; and in this way per- 
haps especially, does it produce emaciation,* 

1617.] A third case of the deficiency of oil may occur 
from the following cause. It is probable, that one purpose 
of the accumulation of oil in the cellular texture of animals 
is, that it may, upon occasion, be again absorbed from 
thence, and carried into the mass of blood, for the purpose 
of enveloping and correcting any unusual acrimony arising 
and existing in the state of the fluids. Thus, in most in- 
stances in which we can discern an acrid state of the fluids, 
as in scurvy, cancer, syphilis, poisons, and several other 
diseases, we find at the same time a deficiency of oil and an 
emaciation take place ; which, in my apprehension, must 
be attributed to the absorption of oil, which the presence 
of acrimony in the body excites. 

It is not unlikely that certain poisons introduced into the 
body, may subsist there ; and, giving occasion to an ab- 
sorption of oil, may lay a foundation for the Tabes a ve- 
7ie?io, Sauv. sp. 17.f 

1618.] A fourth cause of emaciation, and which I would 
attribute to a sudden and considerable absorption of oil from 
the cellular texture, is that of fever, which so generally 
produces emaciation. This may perhaps be in part attri- 
buted to the increased perspiration, and therefore to the ge- 
neral deficiency of fluids that may be supposed to take 
place : but whatever share that may have in producing the 
effect, we can, from the evident shrinking and diminution 
of the cellular substance, wherever it falls under our ob- 
servation, certainly conclude, that there has been a very 
considerable absorption of the oil which had been before de- 
posited in that substance. This explanation is rendered the 
more probable from this, that I suppose the absorption 

• Abstinence trom too severe exercise is the only cure for this species of the disease. 

+ As this kind of emaciation proceeds from various causes, the practitioner must, after having 
ascertained the true cause, endeavor to remove it: and this must be left entirely to his own sa- 
gacity. It may however be prop'-r to observe, that several of these emaciations proceed from 
incurable diseases; as from Canter, Scrophula, &C. and Consequently admit of no cure: and 
those emaciation, which proceed irom scurvy, syphilis, or those diseases which we can cure', are 
only to be cured by curmg toe primary disease. 



PRACTICE OF PHYSIC. .501 

mentioned is necessarily made for the purpose of envelop- 
ing or correcting an acrimony, which manifestly docs in 
many, and may be suspected to arise in all, cases of fever. 
The most remarkable instance of emaciation occurring in 
fevers, is that which appears in the case of hectic fevers. 
Here the emaciation may be attributed to the profuse sweat- 
ings that commonly attend the disease : but there is much 
reason to believe, that an acrimony also is present in the 
blood ; which, even in the beginning of the disease, pre- 
vents the secretion and accumulation of oil ; and in the more 
advanced states of it, must occasion a more considerable 
absorption of it ; which, from the shrinking of the cellular 
substance, seems to go farther than in almost any other 
instance.* 

Upon the subject of emaciations from a deficiency of 
fluids, it may be observed, that every increased evacuation 
excites an absorption from other parts, and particularly 
from the cellular texture ; and it is therefore probable, that 
a deficiency of fluids, from increased evacuations, produces 
an emaciation, not only by the waste of the fluids in the 
vascular system, but also by occasioning a considerable ab- 
sorption from the cellular texture. 

1619.] I have thus endeavored to explain the several 
cases and causes of emaciation ; but I could not prosecute 
the consideration of these here in the order they are set 
down in the Methodical Nosology. In that work I was en- 
gaged chiefly in arranging the Species of Sauvages : but it 
is my opinion now, that the arrangement there given is er- 
roneous, in both combining and separating species impro- 
perly : and it seems to me more proper here to take notice 
of diseases, and put them together, according to the affinity 
of their nature, rather than by that of their external ap- 
pearances. I doubt, if even the distinction of the Tabes 
and Atrophia, attempted in the Nosology, will properly 
apply ; as I think there are certain diseases of the same na- 
ture, which sometimes appear with, and sometimes without, 
fever. 

1620.] After having considered the various cases of 
emaciations, I should perhaps treat of their cure : but iv 
will readily appear, that the greater part of the cases above 
mentioned are purely symptomatic, and consequently that 
the cure of them must be that of the primary diseases upon 

•This emaciation is purely symptomatic, and consequently cannot be cured but by removing 
f 1 e primary disease, and a subsequent very nutritious diet, consisting cbierly of animal food . 



508 PRACTICE OF PHYSIC. 

which they depend. Of those cases that can anywise be 
considered as idiopathic, it will appear that they are to be 
cured entirely by removing the remote causes ; the means 
of accomplishing which must be sufficiently obvious. 



BOOK II. 

OF INTUMESENTIjE, or general 
SWELLINGS. 

1621.] HPHE swellings to be treated of in this place, 

JL are those which extend over the whole or a 

great part of the body ; or such at least, as, though of 

small extent, are however of the same nature with those 

that are more generally extended. 

The swellings comprehended under this artificial order, 
are hardly to be distinguished from one another otherwise 
than by the matter they contain or consist of. And in this 
view I have divided the order into four sections, as the 
swelling happens to contain, 1st, Oil ; 2c/, Air ; 3</, A wa- 
tery fluid ; or, 4th, As the increased bulk depends upon 
the enlargement of the whole substance of certain parts, 
and particularly of one or more of the abdominal viscera. 



CHAPTER I. 

OF ADIPOSE SWELLINGS. 

1622.] nr^HE only disease to be mentioned in this chap- 
JL ter, I have, with other Nosologists, named 
Polysarcia ; and in English it may be named Corpulency, 
or, more strictly, Obesity ; as it is placed here upon the 
common supposition of its depending chiefly upon the in- 
crease of oil in the cellular texture of the body. This cor- 
pulency, or obesity, is in very different degrees in different 
persons, and is often considerable without being considered 
as a disease. There is, however, a certain degree of it, 
which will be generally allowed to be a disease ; as, for 
example, when it renders persons, from a difficult respira- 
tion, uneasy in themselves, and, from the inability of ex- 
ercise, unfit for discharging the duties of life to others : and 



PRACTICE OF PHYSIC. 509 

for that reason I have given such a disease a place here. 
Many physicians have considered it as an object of practice, 
and as giving, even in a very high degree, a disposition to 
many diseases ; I am of opinion that it should be an object 
of practice more frequently than it has been, and therefore 
that it merits our consideration here. 

1623.] It may perhaps be alledged, that I have not been 
sufficiently correct, in putting the disease of corpulency as 
an intumescentia pinguedinosa, and therefore implying its 
being an increase of the bulk of the body from an accumu- 
lation of oil in the cellular texture only. I am aware of 
this objection : and as I have already said, that emaciation 
(1604.) depends either upon a general deficiency of fluids 
in the vascular system, or upon a deficiency of oil in the 
cellular texture ; so 1 should perhaps have observed far- 
ther, that the corpulency, or general fulness of the bodv, 
may depend upon the fulness of the vascular system as well 
as upon that of the cellular texture. This is true; and for 
the same reasons I ought, perhaps, after Linnaeus and Sa- 
gar, to have set down plethora as a particular disease, and 
as an instance of morbid intumescence. I have, however, 
avoided this, as Sauvages and Vogel have done ; because I 
apprehended that plethora is to be considered as a state of 
temperament only, which may indeed dispose to disease ; 
but not as a disease in itself, unless, in the language of the 
Stahlians, it be a plethora commota, when it produces a 
disease accompanied with particular symptoms, which give 
occasion to its being distinguished by a different appella- 
tion. Further, it appears to me, that the symptoms which 
Linnaeus, and more particularly those which Sagar employs 
in the character of plethora, never do occur but when the 
intumescentia pinguedinosa has a great share in producing 
them. It is, however, very necessary to observe here, that 
plethora and obesity are generally combined together ; and 
that in some cases of corpulency it may be difficult to de- 
termine which of the causes has the greatest share in pro- 
ducing it. It is indeed very possible that a plethora may 
occur without great obesity ; but I apprehend that obesity 
never happens to a considerable degree without producing 
a plethora ad spatium in a great part of the system of the 
aorta, and therefore a plethora ad molcm in the lungs, and 
in the vessels of the brain. 

1624.] In attempting the cure of potysarcia, I am of 
opinion that the conjunction of plethora and obesity, in the 



510 PRACTICE OF PHYSIC. 

manner just now mentioned, should be constantly attended 
to ; and when the morbid effects of the plethoric habit are 
threatened, either in the head or lungs, that blood letting 
is to be practised : but at the same time it is to be observed, 
that persons of much obesity do not bear blood-letting well ; 
and when the circumstances I have mentioned do not im- 
mediately require it, the practice upon account of obesity 
alone is hardly ever to be employed. The same remark is 
to be made with respect to any other evacuations that may 
be proposed for the cure of corpulency : for without the 
other means I am to mention, they can give but a very im- 
perfect relief ; and, in so far as they can either empty or 
weaken the system, they may favor the return of pletho- 
ra, and the increase of obesity. 

1625.] Polysarcia, or corpulency, whether it depend 
upon plethora or obesity, whenever it either can be consi- 
dered as a disease or threatens to induce one, is to be cur- 
ed, or the effects of it are to be obviated, by diet and exer- 
cise. The diet must be sparing; or rather, what is more 
admissible, it must be such as affords little nutritious mat- 
ter. It must therefore be chiefly, or almost only, of vegeta- 
ble matter, and at the very utmost of milk. Such a diet 
should be employed, and generally ought to precede exer- 
cise : for obesity does not easily admit of bodily exercise ; 
which is, however, the only mode that can be very effec- 
tual. Such, indeed, in many cases, may seem difficult 
to be admitted ; but I am of opinion, that even the most 
corpulent may be brought to bear it, by at first attempting 
it very moderately, and increasing it by degrees very 
slowly, but at the same time persisting in such attempts 
with great constancy.* 

1626.] As these, though the only effectual measures, 
are often difficult to be admitted or carried into execution, 
some other means have been thought of and employed for 
reducing corpulency. These, if I mistake not, have all 
been certain methods of inducing a saline state in the mass 
of blood ; for such I suppose to be the effects of vinegar 
and of soap, which have been proposed. The latter, I 
believe, hardly passes into the blood-vessels, without being 
resolved and formed into a neutral salt, with the acid which 
it meets with in the stomach. How well acrid and saline 
substances are fitted to diminish obesity, may appear from 

* Besides the means mentioned by the author, evacuations of different kinds ought to be oc - 
ctsionally made, especially by purging and sweating. 



PRACTICE OF PHYSIC. sil 

what has been said above in 1616. What effects vinegar, 
soap, or other substances employed, have had in reducing 
corpulency, there have not proper opportunities of ob- 
serving occurred to me : but I am well persuaded, that the 
inducing a saline and acrid state of the blood, may have 
worse consequences than the corpulency it was intended to 
correct ; and that no person should hazard these, while he 
may have recourse to the more safe and certain means of 
abstinence and exercise. 



CHAPTER II. 

OF FLATULENT SWELLINGS. 

1627.] nr^HE cellular texture of the human body very 
JL readily admits of air, and allows the same 
to pass from any one to every other part of it. Hence 
Emphysemata have often appeared from air collected in 
the cellular texture under the skin, and in several other 
parts of the body. The flatulent swellings under the skin, 
have indeed most commonly appeared in consequence of 
air immediately introduced from without : but in some in- 
stances of flatulent swellings, especially those of the inter- 
nal parts not communicating with the alimentary canal, 
such an introduction cannot be perceived or supposed ; 
and therefore, in these cases, some other cause of the 
production and collection of air must be looked for, though 
it is often not to to be clearly ascertained. 

In every solid as well as every fluid substance which 
makes a part of the human body, there is a considerable 
quantity of air in a fixed state, which may be again re- 
stored to its elastic state, and separated from those sub- 
stances, by the power of heat, putrefaction, and perhaps 
other causes : but which of these may have produced the 
several instances of pneumatosis and flatulent swellings, 
that have been recorded by authors, I cannot pretend to 
ascertain. Indeed upon account of these difficulties, I 
cannot proceed with any clearness on the general subject 
of pneumatosis ; and therefore, with regard to flatulent 
swellings, I find it necessary to confine myself to the consi- 
deration of those of the abdominal region alone ; Avhich I 
shall now treat of under the general name of Tympanites. 

1628.] The tympanites is a swelling of the abdomen ; 



311 PRACTICE OF PHYSIC. 

in which the teguments appear to be much stretched by 
some distending power within, and equally stretched in 
every posture of the body. The swelling does not readily 
yield to any pressure ; and in so far as it does, very quick- 
ly recovers its former state upon the pressure being remov- 
ed. Being struck, it gives a sound like a drum, or other 
stretched animal membranes. No fluctuation within is to 
be perceived ; and the whole feels less Aveighty than might 
be expected from its bulk. The uneasiness of the disten- 
sion is commonly relieved by the discharge of air from the 
alimentary canal, either upwards or downwards. 

1629.] These are the characters by which the tympan- 
ites may be distinguished from the ascites or physconia ; 
and many experiments show, that the tympanites always 
depends upon a preternatural collection of air, somewhere 
within the teguments of the abdomen : but the seat of the 
air is in different cases somewhat different ; and this pro- 
duces the different species of the disease. 

One species is, when the air collected is entirely confin- 
ed within the cavity of the alimentary canal, and chiefly 
in that of the intestines. This species, therefore, is named 
the Tympanites intcstinalis > Sauv. sp. 1. It is, of all others, 
the most common ; and to it especially belong the charac- 
ters given above. 

A second species is, when the air collected is not entire- 
ly confined to the cavity of the intestines, but is also pre- 
sent between their coats ; and such is that which it named 
by Sauvages Tympanites enterophysodes, Sauv. sp. 3. 
This has certainly been a rare occurrence; and has proba- 
bly occurred only in consequence of the tympanites intes- 
tinalis, by the air escaping from the cavity of the intestines 
into the interstices of the coats. It is, however, possible 
that an erosion of the internal coat of the intestines may 
give occasion to the air, so constantly present in their ca- 
vity, to escape into the interstices of their coats, though in 
the whole of their cavity there has been no previous accu- 
mulation. 

A third species is, when the air is collected in the sac of 
the peritonaeum, or what is commonly called the cavity of 
the abdomen, that is, the space between the peritonaeum 
and viscera ; and then the disease is named Tympanites 
abdominalis, Sauv. sp. 2. The existence of such a tym- 
panites, without any tympanites intestinalis, has been dis- 
puted ; and it certainly has been a rare occurrence : but 



PRACTICE OF PHYSIC. 513 

from several dissections, it is unquestionable that such a 
disease has sometimes truly occurred. 

A fourth species of tympanites is, when the tympanites 
intestinalis and abdominalis are joined together, or take 
place at the same time. With respect to this, it is proba- 
ble that the tympanites intestinalis is the primary disease ; 
and the other, only a consequence of the air escaping, by 
an erosion or rupture of the coats of the intestines, from 
the cavity of these into that of the abdomen. It is indeed 
possible that in consequence of erosion or rupture, the air 
which is so constantly present in the intestinal canal, may 
escape from thence in such quantity into the cavity of the 
abdomen, as to give a tympanites abdominalis whilst there 
was no previous considerable accumulation of air in the 
intestinal cavity itself ; but I have not facts to ascertain 
this matter properly. 

A fifth species has also been enumerated. It is when a 
tympanites abdominalis happens to be joined with the hy- 
drops ascites : and such a disease therefore is named by 
Sauvages Tympanites asciticus, Sauv. sp. 4. In most cases 
of tympanites, indeed, some quantity of serum has, upon 
dissection, been found in the sac of the peritonaeum ; but 
that is not enough to constitute the species now mentioned; 
and when the collection of serum is more considerable, it 
is commonly where, both from the causes which have pre- 
ceded, and likewise from the symptoms which attend, the 
ascites may be considered as the primary disease ; and 
therefore that this combination does not exhibit a proper 
species of the tympanites. 

1630.] As this last is not a proper species, and as some 
of the others are not only extremely rare, but even, when 
occurring, are neither primary, nor to be easily distin- 
guished, nor, as considered in themselves, admitting of 
any cure, I shall here take no further notice of them ; 
confining myself in what follows, to the consideration of 
the most frequent case, and almost the only object of prac- 
tice, the Tympanites intestinalis. 

1631.] With respect to this, I cannot perceive that it 
arises in any peculiar temperament, or depends upon any 
predisposition, which can be discerned. It occurs in either 
sex, at every age, and frequently in young persons. 

1632.] Various remote causes of it have been assigned : 
but many of these have not commonly the effect ot pro- 
ducing this disease ; and although some of them have been 

3v 



514 PRACTICE OF PHYSIC. 

truly antecedents of it, I can in few instances discover the 
manner in which they produce the disease, and therefore 
cannot certainly ascertain them to have been causes of it. 

1633.] The phenomena of this disease in its several 
stages are the following : 

The tumor of the belly sometimes grows very quickly 
to a considerable degree, and seldom in the slow manner 
the ascites commonly comes on. In some cases, however, 
the tympanites comes on gradually, and is introduced by 
an unusual flatulency of the stomach and intestines, with 
frequent borborygmy, and uncommonly frequent expul- 
sion of air upwards and downwards. This state is also 
frequently attended with colic pains, especially felt about 
the navel, and upon the sides towards the back ; but gene- 
rally as the disease-advances, these pains become less con- 
siderable. As the disease advances, there is a pretty con- 
stant desire to discharge air, but it is accomplished with 
difficulty ; and when obtained, although it give some re- 
lief from the sense of distention, this relief is commonly 
transient and of short duration. While the disease is 
coming on, some inequality of tumor and tension may be 
perceived in different parts of the belly ; but the disten- 
tion soon becomes equal over the whole, and exhibits the 
phenomena mentioned in the character. Upon the first 
coming on of the disease, as well as during its progress, 
the belly is bound, and the faeces discharged are common- 
ly hard and dry. The urine, at the beginning, is usually 
very little changed in quantity or quality from its natural 
state : but as the disease continues, it is commonly chang- 
ed in both respects; and at length sometimes a stranguary, 
and even an ischuria, comes on. The disease has seldom 
advanced far, before the appetite is much impaired, and 
digestion ill performed : and the whole body, except the 
belly, becomes considerably emaciated. Together with 
these symptoms, a thirst and uneasy sense of heat at length 
come on, and a considerable frequency of pulse occurs, 
which continues throughout the course of the disease. 
When the tumor of the belly arises to a considerable bulk, 
the breathing becomes very difficult, with a frequent dry 
cough. With all these symptoms the strength of the pa- 
tient declines : and the febrile symptoms daily increasing 
death at length ensues, sometimes probably in consequence 
of a gangrene coming upon the intestines. 

1634.] The tympanites is commonly of some duration. 



PRACTICE OF PHYSIC. 515 

and to be reckoned a chronic disease. It is very seldom 
quickly fatal, except where such an affection suddenly 
arises in fevers. To this Sauvages has properly given a 
different appellation, that of Meteorismus ; and I judge 
it may always be considered as a symptomatic affection, en- 
tirely distinct from the tympanites we are now considering. 

1635.] The tympanites is generally a fatal disease, sel- 
dom admitting of cure : but what may be attempted in this 
way, I shall try to point out, after I shall have endeavor- 
ed to explain the proximate cause, which alone can lay 
the foundation of what may be rationally attempted to- 
wards its cure. 

1636.] To ascertain the proximate cause of tympanites, 
is somewhat difficult. It has been stipposed in many casei, 
to be merely an uncommon quantity of air present in the 
alimentary canal, owing to the extrication and detachnv.,it 
of a greater quantity of air than usual from the alimentary 
matters taken in. Our vegetable aliments, I believe, al- 
ways undergo some degree of fermentation ; and in conse- 
quence, a quantity of air is extricated and detached from 
them in the stomach and intestines : but it appears, that 
the mixture of the animal fluids which our aliments meet 
with in the alimentary canal, prevents the same quantity 
of air from being detached from them that would have 
been in their fermentation without such mixture ; and it is 
probable that the same mixture contributes also to the re- 
absorption of the air that had been before in some measure 
detached. The extrication, therefore, of an unusual quan- 
tity of air from the aliments, may, in certain circumstan- 
ces, be such, perhaps as to produce a tympanites : so that 
this disease may depend upon a fault of the digestive flu- 
ids, whereby they are unfit to prevent the too copious ex- 
trication of air, and unfit also to occasion that reabsorp- 
tion of air which in sound persons commonly happens. An 
unusual quantity of air in the alimentary canal, whether 
owing to the nature of the aliments taken in, or to the fault 
of the digestive fluid, does certainly sometimes take place; 
and may possibly have, and in some measure certainly has, 
a share in producing certain flatulent disorders of the ali- 
mentary canal ; but cannot be supposed to produce the 
tympanites, which often occurs when no previous disorder 
had appeared in the system. Even in those cases of tvm- 
-panites which are attended at their beginning with flatu- 
lent disorders in the whole of the alimentary canal, as we 



516 PRACTICE OF PHYSIC. 

know that a firm tone of the intestines both moderates the 
extrication of air and contributes to its reabsorption or rea- 
dy expulsion, so the flatulent symptoms which happen to 
appear at the coming on of a tympanites, are, in my opi- 
nion, to be referred to a loss of tone in the muscular fibres 
of the intestines, rather than to any fault in the diges- 
tive fluids. 

1637.] These, and other considerations, lead me to con- 
clude, that the chief part of the proximate cause of tympa- 
nites, is a loss of tone in the muscular fibres of the intes- 
tines. But further, as air of any kind accumulated in the 
cavity of the intestines should, even by its own elasticity, 
find its way either upwards or downwards, and should also, 
by the assistance of inspiration, be entirely thrown out of 
the body ; so, when neither the reabsorption nor the ex- 
pulsion takes place, and the air is accumulated so as to 
produce tympanites, it is probable that the passage of the 
air along the course of the intestines is in some places of 
these interrupted. This interruption, however, can hardly 
be supposed to proceed from any other cause than spas- 
modic constrictions in certain parts of the canal ; and I 
conclude, therefore, that such constrictions concur as part 
in the proximate cause of tympanites. — Whether these 
spasmodic constrictions are to be attributed to the remote 
cause of the disease, or may be considered as the conse- 
quence of some degree of atony first arising, I cannot with 
certainty, and do not find it necessary to determine. 

1638.] Having thus endeavored to ascertain the proxK 
mate cause of tympanites, I proceed to treat of its cure ; 
which indeed has seldom succeeded, and almost never but 
in a recent disease. I must, however, endeavor to say 
what may be reasonably attempted ; what has commonly 
been attempted ; and what attempts have sometimes suc- 
ceeded in the cure of this disease. 

1639.] It must be a first indication to evacuate the air 
accumulated in the intestines : and for this purpose it is ne- 
cessary that those constrictions, which had especially occa- 
sioned its accumulation, and continue to interrupt its pas- 
sage along the course of the intestines should be removed. 
As these, however, can hardly be removed but by exciting 
the peristaltic motion in the adjoining portions of the intes- 
tines, purgatives have been commonly employed ; but it is 
at the same time agreed, that the more gentle laxatives on- 
ly ought to be employed, as the more drastic, in the over- 



PRACTICE OF PHYSIC. 511 

stretched and tense state of the intestines, are in danger of 
bringing on inflammation. 

It is for this reason, also, that glysters have been fre- 
quently employed ; and they are the more necessary, as the 
faeces collected are generally found to be in a hard and dry 
state. Not only upon account of this state of the faeces, 
but, farther, when glysters produce a considerable evacu- 
ation of air, and thus show that they have some effect in 
relaxing the spasms of the intestines, they ought to be re- 
peated very frequently. 

1640.] In order to take off the constrictions of the intes- 
tines, and with some view also to the carminative effects of 
the medicines, various antispasmodics have been proposed, 
and commonly employed ; but their effects are seldom con- 
siderable, and it is alledged that their heating and inflam- 
matory powers have sometimes been hurtful. It is, how- 
ever, always proper to join some of the milder kinds with 
both the purgatives and glysters that are employed ;* and 
it has been very properly advised to give always the chief 
of antispasmodics, that is, an opiate, after the operation 
of purgatives is finished. 

1641.] In consideration of the overstretched, tense, and 
dry state of the intestines, and especially of the spasmodic 
constrictions that prevail, fomentations and warm bathing 
have been proposed as a remedy ; and are said to have been 
employed with advantage : but it has been remarked, that 
very warm baths have not been found so useful as tepid 
baths long continued. 

1642.] Upon the supposition that this disease depends 
especially upon an atony of the alimentary canal, tonic re- 
medics seem to be properly indicated. Accordingly cha- 
lybeates, and various bitters, have been employed ; and if 
any tonic, the Peru vain bark might probably be useful. 

1643.] But as no tonic remedy is more powerful than 
cold applied to the surface of the body, and cold drink 
thrown into the stomach ; so such a remedy has been thought 
of in this disease. Cold drink has been constantly prescrib- 
ed, and cold bathing has been employed with advantage; 
and there have been several instances of the disease being 

• The antispasmodics that are to be joined with purgatives, ou-ht to be essential oils, espe- 
cially the essential oils of umbelliferous plants, as oil of aniseed, oil of carui, &c. and their doss 
ou-ht to be moderate. In manv cases thev may be used id repeated small doses by themselves 
on a piece of sus;ar. The dose of the ol. anisi ought not to exceed ten or twelve drops, nor of 
the ol. carui five drops; larger doses are too heating. It may be proper also to observe, that 
•he essential oils of the verticellatcd plants, as mint, marjoram, thyme, &c. are much to j hea: - 
ieg, and much more so those of the aiotnaucs, as cloves, cinnamon, &c 



518 PRACTICE OF PHYSIC. 

suddenly and entirely cured by the repeated application 
of snow to the lower belly. 

1644.] It is hardly necessary to remark, that, in the diet 
of tympanitic persons, all sorts of food ready to become 
flatulent in the stomach are to be avoided ; and it is proba- 
ble, that the fossil acids and neutral salts, as antizymics, 
may be useful.* 

1645.] In obstinate and desperate cases of tympanites, 
the operation of the paracentesis has been proposed : but it 
is a very doubtful remedy, and there is hardly any testi- 
mony of its having been practised with success. It must 
be obvious, that this operation is a remedy suited especially, 
and almost only, to the tympanites abdominalis ; the ex- 
istence of which, separately from the intestinalis, is very 
doubtful, at least not easily ascertained. Even if its ex- 
istence could be ascertained, yet it is not very likely to be 
cured by this remedy ; and how far the operation might be 
safe in the tympanites intestinalis, is not yet determined by 
any proper experience. 



CHAPTER III. 
OF WATERY SWELLINGS, OR DROPSIES. 

1646.] A PRETERNATURAL collection of serous 
±\ or watery fluids, is often formed in different 
parts of the human body ; and although the disease thence 
arising be distinguished according to the different parts 
which it occupies, yet the whole of such collections come 
under the general appellation of Dropsies. At the same 
time, although the particular instances of such collection 
are to be distinguished from each other according to the 
parts they occupy, as well as by other circumstances at- 
tending them ; yet all of them seem to depend upon some 
general causes, very much in common to the whole. Before 
proceeding, therefore, to consider the several species, it 
may be proper to endeavor to assign the general causes of 
dropsy. 

1647.] In persons of health, a serous or watery fluid 
seems to be constantly poured out, or exhaled in vapor, into 
every cavity and interstice of the human body capable of 

• The fossil acids are undoubtedly very powerful in resisting fermentation : and if the air » 
the tntejimes is produced by fetmenUucn, -they are consequently highly useful. 



PRACTICE OF PHYSIC. 519 

receiving it ; and the same fluid, without remaining long or 
being accumulated in these spaces, seems constantly to be 
soon again absorbed from thence by vessels adapted to the 
purpose. From this view of the animal economy, it will 
be obvious, that if the quantity poured out into any space, 
happens to be greater than the absorbents can at the same 
time take up, an unusual accumulation of serous fluid will 
be made in such parts; or though the quantity poured out 
be not more than usual, yet if the absorption be anywise 
interrupted or diminished, from this cause also an unusual 
collection of fluids may be occasioned. 

Thus, in general, dropsy may be imputed to an increased 
effusion, or to a diminished absorption ; and I therefore pro- 
ceed to inquire into the several causes of these. 

1648 ] An increased effusion may happen, either from a 
preternatural increase of the ordinary exhalation, or from 
the rupture of vessels carrying, or of sacs containing, serous 
or watery fluids. 

1649.] The ordinary exhalation may be increased by va- 
rious causes, and particularly by an interruption given to 
the free return of the venous blood from the extreme ves- 
sels of the body to the right ventricle of the heart. This 
interruption seems to operate by resisting the free passage 
of the blood from the arteries into the veins, thereby increas- 
ing the force of the arterial fluids in the exhalants, and con- 
sequently the quantity of fluid which they pour out. 

1650.] The interruption of the free return of the venous 
blood from the extreme vessels, may be owing to certain cir- 
cumstances affecting the course of the venous blood ; very 
frequently, to certain conditions in the right ventricle of the 
heart itself, preventing it from receiving the usual quantity 
of blood from the vena cava ; or to obstructions in the ves- 
sels of the Jungs preventing the entire evacuation of the 
right ventricle, and thereby hindering its receiving the 
usual quantity of blood from the cava. Thus, a polypus 
in the right ventricle of the heart, and the ossification of its 
valves, as well as all considerable and permanent obstruc- 
tions of the lungs, have been found to be causes of dropsy. 

1651.] It may serve as an illustration of the operation of 
these general causes, to remark, that the return of the ve- 
nous blood is in some measure resisted when the posture of 
the body is such as gives occasion to the gravity of the blood 
to oppose the motion of it in the veins, which takes effect 
when- the force of the circulation is weak ; and from whence 



520 PRACTICE OF PHYSIC. 

it is that an upright posture of the body produces or in- 
creases serous swellings in the lower extremities. 

1652.] Not only those causes interrupting the motion of 
the venous blood more generally, but, farther, the inter- 
ruption of it in particular veins, may likewise have the ef- 
fect of increasing exhalation, and producing dropsy. The 
most remarkable instance of this is, when considerable ob- 
structions of the liver prevent the blood from flowing freely 
into it from the vena portarum and its numerous branches ; 
and hence these obstructions arc a frequent cause of dropsy. 

1653.] Scirrhosities of the spleen and other viscera, as 
well as the scirrhosity of the liver, have been considered as 
causes of dropsy ; but the manner in which they can pro- 
duce the disease, I do not perceive, except it may be where 
they happen to be near some considerable vein, by the com- 
pression of which they may occasion some degree of ascites ; 
or, by compressing the vena cava, may produce an anasarca 
of the lower extremities. It is indeed true, that scirrhosi- 
ties of the spleen and other viscera, have been frequently 
discovered in the bodies of hydropic persons : but I believe 
that they have been seldom found unless when scirrhosities 
of the liver were also present ; and I am inclined to think, 
that the former have been the effects of the latter, rather 
than the cause of the dropsy ; or that, if scirrhosities of the 
other viscera have appeared in hydropic bodies when that of 
the liver was not present, they must have been the effects 
of some of those causes of dropsy to be hereafter mention- 
ed ; and consequently to be the accidental attendants, rather 
than the causes, of such dropsies. 

1654.] Even in smaller portions of the venous system, 
the interruption of the motion of the blood in particular 
veins has had the same effect. Thus a polypus formed in 
the cavity of a vein, or tumors formed in its coats, prevent- 
ing the free passage of the blood through it, have had the 
effect of producing dropsy in parts towards the extremity 
of such veins. 

1655.] But the cause most frequently interrupting the 
motion of the blood through the veins is, the compression 
of tumors existing near to them ; such as aneurisms in the 
arteries, abscesses, and scirrhous or steal omatous tumors in 
the adjoining parts. 

To this head may be referred the compression of the de- 
scending cava by the bulk of the uterus in pregnant women, 
and the compression of the same by the bulk of water in the 



PRACTICE OF PHYSIC. 52\ 

ascites ; both of which compressions frequently produce se- 
rous swellings in the lower extremities. 

1656.] It may be supposed, that a general preternatural 
plethora of the venous system may have the effect of in- 
creasing exhalation ; and that this plethora may happen 
from the suppression of fluxes, or evacuations of blood, 
which had for some time taken place in the body, such as 
the menstrual and hemorrhoidal fluxes. A dropsy, how- 
ever, from such a cause, has been at least a rare occurrence ; 
and when it seems to have happened, I should suppose it 
owing to the same causes as the suppression itself, rather 
than to the plethora produced by it. 

1657.] One of the most frequent causes of an increased 
exhalation, I apprehend to be the laxity of the exhalant 
vessels. That such a cause may operate, appears probable 
from this, that paralytic limbs, in which such a laxity is to 
be suspected, are frequently affected with serous, or as 
they are called, cedematous swellings. 

But a much more remarkable and frequent example of 
its operation occurs in the case of a general debility of the 
system, -which is so often attended with dropsy. That a 
general debility does induce dropsy, appears sufficiently 
from its being so commonly the consequence of powerfully 
debilitating causes ; such as fevers, either of the continued 
or intermittent kind, which have lasted long ; long con- 
tinued and somewhat excessive evacuations of any kinds ; 
and in short, almost all diseases that have been of long con- 
tinuance, and have at the same time induced the other 
symptoms of a general debility. 

Among other causes inducing a general debility of the 
system, and thereby dropsy, there is one to be mentioned 
as frequently occurring, and that is, intemperance in the 
use of intoxicating liquors ; from whence it is that drunk- 
ards of all kinds, and especially dram-drinkers, are so af- 
fected with this disease. 

1658.] That a general debility may produce a laxity of 
the exhalants, will be readily allowed : and that by this es- 
pecially it occasions dropsy, I judge from thence, that while 
most of the causes already mentioned are suited to produce 
dropsies of particular parts only, the state of general debi- 
lity gives rise to an increased exhalation into every cavity 
and interstice of the body, and therefore brings on a general 
disease. Thus, we have seen effusions of a serous fluid 
made, at the same time, into the cavity of the cranium, in- 



522 PRACTICE OF PHYSIC. 

to that of the thorax and the abdomen, and likewise inta 
the cellular texture almost over the whole of the body. In 
such cases, the operation of a general cause discovered it- 
self, bv these several dropsies increasing in one part as they 
diminish in another, and this alternately in the different 
parts. This combination, therefore, of the different spe- 
cies of dropsy, or rather, as it may be termed, this univer- 
sal dropsy, must, I think, be referred to a general cause , 
and in most instances, hardly any other can be thought of, 
but a general laxity of the exhalants. It is this, therefore, 
that I call the hydropic diathesis ; which frequently operates 
by itself ; and frequently, in some measure, concurring 
with other causes, is especially that which gives them their 
full effect. 

This state of the system, in its first appearance, seems to 
be what has been considered as a particular disease under 
the name of Cachexy ; but in every instance of it that has 
occurred to me, I have always considered, and have always 
found, it to be the beginning of general dropsy. 

J 659.] The several causes of dropsy already mentioned 
may produce the disease, although there be no preternatu- 
ral abundance of serous or watery fluid in the blood-ves- 
sels ; but it is now to be remarked, that a preternatual 
abundance of that kind may often give occasion to the dis- 
ease, and more especially when such abundance concurs 
with the causes above enumerated. 

One cause of such preternatural abundance may bean 
unusual quantity of water taken into the body. Thus, an 
unusual quantity of water taken in by drinking, has some- 
times occasioned a dropsy. Large quantities of water, it is 
true, are upon many occasions taken in ; and being as rea- 
dily thrown out again by stool, urine, or perspiration, have 
not produced any disease. But it is also certain, that, upon 
some occasions, an unusual quantity of watery liquors tak- 
en in has run off by the several internal exhalants, and pro- 
duced a dropsy. This seems to have happened, either 
from the excretories not being fitted to throw out the fluid 
so fast as it had been taken in, or from the excretories hav- 
ing been obstructed by accidentally concurring causes. 
Accordingly it is said, that the sudden taking in of a large 
quantity of very cold water, has produced dropsy, probably 
from the cold producing a constriction of the excre- 
tories. 

The proportion of watery fluid in the blood may be in- 



PRACTICE OF PHYSIC. 523 

creased, not only by the taking in a large quantity of water 
by drinking, as now mentioned, but it is possible that it 
may be increased also by water taken in from the atmos- 
phere by the skin in an absorbing or imbibing state. It is 
well known that the skin may be, at least, occasionally in 
such a state ; and it is probable, that in many cases of begin- 
ning dropsy, when the circulation of the blood on the sur- 
face of the body is very languid, that the skin may be 
changed from a perspiring to an imbibing state ; and thus, 
at least, the disease may be very much increased. 

1660.] A second cause of a preternatural abundance of 
watery fluids in the blood-vessels, may be, an interruption 
of the ordinary watery excretions ; and accordingly it is 
alledged, that persons much exposed to a cold and moist air 
are liable to dropsy. It is also said, that an interruption, 
or considerable diminution, of the urinary secretion, has 
produced the disease; and it is certain, that, in the case of 
an ischuria renalis, the serosity retained in the blood-ves- 
sels has been poured out into some internal cavities, and has 
occasioned dropsy. 

1661.] A third cause of an over proportion of serous 
fluid in the blood ready to run oft" by the exhalants, has been 
very large evacuations of blood, either spontaneous or arti . 
ficial. These evacuations, by abstracting a large propor- 
tion of red globules and gluten, which are the principal 
means of retaining serum in the red vessels, allow the serum 
to run off more readily by the exhalants: and hence dropsies 
have been frequently the consequence of such evacuations. 

It is possible also, that large and long-continued issues, 
by abstracting a large proportion of gluten, may have the 
same effect. 

An over-proportion of the serous parts of the blood, may 
not only be owing to the spoliation just now mentioned, but 
may, I apprehend, be likewise owing to a fault in the digest- 
ing and assimilating powers in the stomach and other organs; 
whereby they do not prepare and convert the aliments taken 
in, in such a manner as to produce from them the due pro- 
portion of red globules and gluten ; but, still continuing to 
supply the watery parts, occasion these to be in an over- 
proportion, and consequently ready to run off in too large 
quantity by the exhalants. It is in this manner that we ex- 
plain the dropsy, so often attending chlorosis: which ap- 
pears always at first by a pale color of the whole body, 
showing a manifest deficiency of red blood ; which in that 



524 PRACTICE OF PHYSIC. 

disease can only be attributed to an imperfect digestion and 
assimilation. 

Whether a like imperfection takes place in what has been 
called a Cachexy, I dare not determine. This disease indeed 
has been commonly and verv evidently owing to the general 
causes of debility above-mentioned : and it being probable 
that the general debility may affect the organs of digestion 
and assimilation ; so the imperfect state of these functions, 
occasioning a deficiency of red globules and gluten, may 
often concur with the laxity of the exhalants in producing 
dropsy. 

1662.] These are the several causes of increased exhala- 
tion, which I have mentioned as the chief cause of the effu- 
sion producing dropsy ; but I have likewise observed in 
1648, that with the same effect, an effusion may also be made 
by the rupture of vessels carrying watery fluids. 

In this way, a rupture of the thoracic duct, has given oc- 
casion to an effusion of chyle and lymph into the cavity of 
the thorax ; and a rupture of the lacteals has occasioned a 
like effusion into the cavity of the abdomen ; and in either 
case, a dropsy has been produced. 

It is sufficiently probable, that a rupture of lymphatics, 
in consequence of strains, or the violent compression of 
neighboring muscles, has occasioned an effusion ; which, 
being diffused in the cellular texture, has produced dropsy. 

It belongs to this head of causes, to remark, that there 
are many instances of a rupture or erosion of the kidneys, 
ureters, and bladder of urine ; whereby the urine has been 
poured into the cavity of the abdomen, and produced an 
ascites. 

1663.] Upon this subject, of the rupture of vessels car- 
rying, or of vesicles containing, watery fluids, I must ob- 
serve, that the dissection of dead bodies has often shown 
vesicles formed upon the surface of many of the internal 
parts ; and it has been supposed, that the rupture of such 
vesicles, commonly named Hydutides, together with their 
continuing to pour out a watery fluid, has been frequently 
the cause of dropsy. I cannot deny the possibility of such 
a cause, but suspect the matter must be explained in a dif- 
ferent manner. 

There have been frequently found, in almost every dif- 
ferent part of animal bodies, collections of spherical vesi- 
cles, containing a watery fluid ; and in many cases of sup- 
posed dropsy, particularly in those called the preternatural 



PRACTICE OF PHYSIC. 525 

encysted dropsies, the swelling has been entirely owing to 
a collection of such hydatides. Many conjectures have 
been formed with regard to the nature and production of 
these vesicles : but the matter at last seems to be ascertain- 
ed. It seems to be certain, that each of these vesicles has 
within it, or annexed to it, a living animal of the worm 
kind ; which seems to have the power of forming a vesicle 
for the purpose of its own economy, and of filling it with a 
watery fluid drawn from the neighbouring parts : and this 
animal has therefore been properly named by late natura- 
lists the Taenia hydatigena. The origin and economy of 
this animal, or an account of the several parts of the hu- 
man body which it occupies, I cannot prosecute further 
here ; but it was proper for me, in delivering the causes of 
dropsy, to say thus much of hydatides . and I must con- 
clude with observing, I am well persuaded, that most of 
the instances of preternatural encysted dropsies which have 
appeared in many different parts of the human body, have 
been truly collections of such hydatides ; but how the 
swellings occasioned by these are to be distinguished from 
other species of dropsy, or how they are to be treated in 
practice, I cannot at present determine. 

1654.] After having mentioned these, I return to consi- 
der the other general cause of dropsy, which I have said 
in 1647 may be, An interruption or diminution of the 
absorption that should take up the exhaled fluids from the 
several cavities and interstices of the body ; the causes of 
which interruption, however, are not easily ascertained. 

1665.] It seems probable, that absorption may be dimin- 
ished, and even cease altogether, from a loss of tone in 
the absorbent extremities of the lympathics. I cannot in- 
deed doubt that a certain degree of tone or active power 
is necessary in these absorbent extremities ; and it appears 
probable, that the same general debility which produces 
that laxity of the exhalant vessels, wherein I have supposed 
the hydropic diathesis to consist, will at the same time oc- 
casion a loss of tone in the absorbents ; and therefore that 
a laxity of the exhalants will generally be accompanied 
with a loss of tone in the absorbents ; and that this will have 
a share in the production of dropsy. Indeed it is probable 
that the diminution of absorption has a considerable share 
in the matter ; as dropsies are often cured by medicines 
which seem to operate by exciting the action of the absorb- 
ents. 



526 PRACTICE OF PHYSIC. 

1666.] It has been supposed, that the absorption per- 
formed by the extremities of lympathics may be interrupt- 
ed by an obstruction of these vessels, or at least of the con- 
globate glands through which these vessels pass. This, 
however, is very doubtful. As the lymphatics have branch- 
es frequently communicating with one another, it is not 
probable that the obstruction of any one, or even several 
of these, can have any considerable effect in interrupting 
the absorption of their extremities. 

And for the same reason it is as little probable that the 
obstruction of conglobate glands can have such an effect : 
at least it is only an obstruction of the glands of the mesen- 
tery, through which so considerable a portion of the lymph 
passes, that can possibly have the effect of interrupting 
absorption. But even this we should not readily suppose, 
there being reason to believe that these glands, even in a 
considerably tumefied state, are not entirely obstructed: 
and accordingly I have known several instances of the 
most part of the mesenteric glands being considerably 
tumefied, without either interrupting the transmission of 
fluids to the blood-vessels, or occasioning anv dropsy. 

An hydropic swelling, indeed, seems often to affect the 
arm from a tumor of the axillary gland : but it seems to 
me doubtful, whether the tumor of the arm may not be 
owing to some compression of the axillary vein, rather than 
to an obstruction of the lymphatics. 

1667.] A particular interruption of absorption may be 
supposed to take place in the brain. As no lymphatic ves- 
sels have yet very certainly been discovered in that organ, 
it may be thought that the absorption, which certainly 
takes place there, is performed by the extremities of veins, 
or by vessels that carry the fluid directly into the veins; so 
that any impediment to the free motion of the blood in the 
veins of the brain, may interrupt the absorption there, and 
occasion that accumulation of serous fluid which so fre- 
quently occurs from a congestion of blood in these veins. 
But I give all this as a matter of conjecture only. 

1668.] Having thus explained the general causes of 
dropsy, I should proceed, in the next place, to mention 
the several parts of the body in which serous collections 
take place, and so to mark the different species of dropsy : 
but I do not think it necessary for me to enter into any 
minute detail upon this subject. In many cases, these col- 
lections, are not to be ascertained by any external symp- 



PRACTICE OF PHYSIC. 527 

toms and therefore cannot be the objects of practice ; and 
many of them, though in some measure discernible, do not 
seem to be curable by our art. I the more especially avoid 
mentioning very particularly the several s*pecies, because 
that has already been sufficiently done by Dr. D. Monro, 
and other writers in every body's hands. I must confine 
myself here to the consideration of those species which are 
the most frequently occurring and the most common ob- 
jects of our practice ; which are, the Anasarca, Hydro- 
thorax, and Ascites and each of these I shall treat of in so 
many separate sections. 



SECTION I. 
Of Anasarca. 



1669.] THE Anasarca is a swelling upon the surface of 
the body, at first commonly appearing in particular parts 
only, but at length frequently appearing over the whole. 
So far as it extends, it is an uniform swelling over the 
whole member, at first always soft, and readily receiving 
the pressure of the finger, which forms a hollow that re- 
mains for some little time after the pressure is removed, 
but at length rises again to its former fulness. This swel- 
ling generally appears, first, upon the lower extremities : 
and there too only in the evening, disappearing again in the 
morning. It is usually more considerable as the person 
has been more in an erect posture during the day ; but 
there are many instances of the exercise of walking pre- 
venting altogether its otherwise usual coming on. Al- 
though this swelling appears at first only upon the feet and 
about the ankles ; yet if the causes producing it continue 
to act, it gradually extends upwards, occupying the legs, 
thighs, and trunk of the body, and sometimes even the 
head. Commonly the swelling of the lower extremities di- 
minishes during the night; and in the morning, the swel- 
ling of the face is most considerable, which again generally 
disappears almost entirely in the course of the day. 

1670.] The terms of Anasarca and Ltucophlegmatia 
have been commonly considered as synonymous : but some 
authors have proposed to consider them' as denoting dis- 
tinct diseases. The authors who are of this last opinion em- 
ploy the name of Anasarca for that disease which begins 



528 PRACTICE OF PHYSIC. 

in the lower extremities, and is from thence gradually ex- 
tended upwards in the manner I have just now described ; 
while the term Leucophlematia, that in which the same 
kind of swelling appears even at first very generally over 
the whole body. They seem to think also, that the two 
diseases proceed from different causes ; and that, while the 
anasarca may arise from the several causes in 1649 — 
1660, the leucophlegmatia proceeds especially from a 
deficiency of red blood, as we have mentioned in 1661, 
et seq. I cannot, however, find any proper foundation for 
this distinction. For although in dropsies proceeding 
from the causes mentioned in 1661, et seq. the disease ap- 
pears in some cases more immediately affecting the whole 
body ; yet that does not establish a difference from the 
common case of anasarca : for the disease, in all its cir- 
cumstances, comes at length to be entirely the same ; and 
in cases ocasioned by a deficiency of red blood, I have 
frequently observed it to come on exactly in the manner of 
an anasarca, as above described. 

1671.] An anasarca is evidently a preternatural collec- 
tion of serous fluid in the cellular texture immediately un- 
der the skin. Sometimes pervading the skin itself, it oozes 
out through the pores of the cuticle ; and sometimes, too 
gross to pass by these, it raises the cuticle in blisters. Some- 
times the skin, not allowing the water to pervade it, is com- 
pressed and hardened, and at the same time so much dis- 
tended, as to give anasarcous tumors an unusual firmness. 
It is in these last circumstances also that an erythematic in- 
flammation is ready to come upon anasarcous swellings. 

1672.] An anasarca may immediately arise from any of 
the several causes of dropsy which act more generally upon 
the system : and even when other species of dropsy, from 
particular circumstances, appear first ; yet whenever these 
proceed from any causes more generally affecting the sys- 
tem, an anasarca sooner or later comes always to be joined 
with them. 

1673.] The manner in which this disease commonly first 
appears, will be readily explained by what I have said in 
1651 , respecting the effects of the posture of the body. Its 
gradual progress, and its affecting, after some time, not only 
the cellular texture under the skin, but probably also much 
of the same texture in the internal parts, will be understood 
partly from the communication that is readily made between 
the several parts of the cellular texture; but especially from 



PRACTICE OF PHYSIC. 529 

the same general causes of the disease producing their ef- 
fects in every part of the body. It appears to me, that the 
water of anasarcous swellings is more readily communicated 
to the cavity of the thorax, and to the lungs, than to the 
cavity of the abdomen, or to the viscera contained in it. 

1674.] An anasarca is almost always attended with a 
scarcity of urine ; and the urine voided, is, from its scar- 
city, always of a high color ; and from the same cause, 
after cooling, readily lets fall a copious reddish sediment. 
This scarcity of urine may sometimes be owing to an ob- 
struction of the kidneys ; but probably is generally occa- 
sioned by the watery parts of the blood running off into 
the cellular texture, and being thereby prevented from 
passing in the usual quantity to the kidneys. 

The disease is also generally attended with an unusual 
degree of thirst ; a circumstance I would attribute to a 
like abstraction of fluid from the tongue and fauces, which 
are extremely sensible to every diminution of the fluid in 
these parts. 

1675.] The cure of anasarca is to be attempted upon 
three general indications. 

1. The removing the remote causes of the disease. 

2. The evacuation of the serous fluid already collected 
in the cellular texture. 

3. The restoring the tone of the system, the loss of 
which may be considered in many cases as the proximate 
cause of the disease. 

1676.] The remote causes are very often such as had 
not only been applied, but had also been removed* long 
before the disease came on. Although, therefore, their ef- 
fects remain, the causes themselves cannot be the objects 
of practice ; but if the causes still continue to be applied, 
such as intemperance, indolence, and some others, they 
must be removed. For the most part, the remote causes 
are certain diseases previous to the dropsy, which are to be 
cured by the remedies particularly adapted to them, and 
cannot be treated of here. The curing of these, indeed, 
may be often difficult ; but it was proper to lay down the 
present indication, in order to show, that when these re- 
mote causes cannot be removed, the cure of the dropsy 
must be difficult, or perhaps impossible. In may cases, 
therefore, the following indications will be to little pur- 

• These are large evacuations of different kinds, but especially bxmorrhagies, which hare 
ceased before the dropsy came on. 

St 



530 PRACTICE OF PHYSIC. 

pose ; and particularly, that often the execution of the se- 
cond, will not only give the patient a great deal of fruit- 
less trouble, but commonly also hurry on his fate. 

1677.] The second indication for evacuating the col- 
lected serum, may be sometimes executed with advantage, 
and often, at least, with temporary relief. It may be per- 
formed in two ways. First, by drawing off the water di- 
rectly from the dropsical part, by openings made into it 
for that purpose : or, secondly, by exciting certain serous 
excretions ; in consequence of which, an absorption may 
be excited in the dropsical parts, and thereby the serum 
absorbed and carried into the blood-vessels may afterwards 
be directed to run out, or may spontaneously pass out, by 
one or other of the common excretions. 

1678.] In an anasarca, the openings into the dropsical 
part are commonly to be made in some part of the lower 
extremities ; and will be most properly made by many 
small punctures reaching the cellular texture. Formerly, 
considerable incisions were employed for this purpose : 
but as any wound made in dropsical parts, which, in or- 
der to their healing, must necessarily inflame and suppu- 
rate, are liable* to become gangrenous ; so it is found to 
be much safer to make the openings by small punctures 
only, which may heal up by the first intention. At the 
same time, even with respect to these punctures, it is pro- 
per to observe, that they should be made at some distance 
from one another, and that care should be taken to avoids 
making them in the most depending parts. 

1 679.] The water of anasarcous limbs may be some- 
times drawn off by pea-issues, made by caustic a little be- 
low the knees : for as the great swelling of the lower ex- 
tremities is chiefly occasioned by the serous fluid exhaled 
into the upper parts constantly falling down to the lower ; 
so the issues now mentioned, by evacuating the water 
from the upper parts, may very much relieve the whole 
of the disease. Unless, however, the issues be put in be- 
fore the disease is far advanced, and before the parts have 
very much lost their tone, the places of the issues are rea- 
dy to become affected with gangrene. 

Some practical writers have advised the employment of 
setons, for the same purpose that I have proposed issues ; 

* Peculiarly liable in this disease on account of the diminished tone, and consequently thecuL- 
minished strength of the parts. 



PRACTICE OF PHYSIC. 531 

but I apprehend, that setons will be more liable than issues 
to the accident just now mentioned. 

1680.] For the purpose of drawing out serum from 
anasarcous limbs, blisters have been applied to them, and 
sometimes with great success ; but the blistered parts are 
ready to have a gangrene come upon them. Blistering is 
therefore to be employed with great caution : and perhaps 
only in the circumstances that I have mentioned above to 
be fit for the employment of issues. 

1681.] Colewort-leaves applied to the skin, readily oc- 
casion a watery exsudation from its surface ; and applied 
to the feet and legs affected with anasarca, have some- 
times drawn off the water very copiously, and with great 
advantage. 

Analogous, as I judge, to this, oiled silk-hose put upon 
the feet and legs, so as to shut out all communication with 
the external air, have been found sometimes to draw a 
quantity of water from the pores of the skin, and are said 
in this way to have relieved anasarcous swellings ; but in 
several trials made, I have never found either the applica- 
tion of these hose, or that of the colewort-leaves, of much 
service.* 

1682.] The second means proposed in 1677, for drawing 
off the water from dropsical places, may be the employ- 
ment of emetics, purgatives, diuretics, or sudorifics. 

1683.] As spontaneous vomiting has sometimes excited 
an absorption in hydropic parts, and thereby drawn off the 
waters lodged in them, it is reasonable to suppose that vo- 
miting excited by art may have the same effect ; and ac- 
cordingly it has been often practised with advantage. The 
practice, however, requires that the strong antimonial 
emetics be employed, and that they be repeated frequently 
after short intervals. 

1684.] Patients submit more readily to the use of pur- 
gatives, than to those of emetics ; and indeed they com- 
monly bear the former more easily than the latter. At the 
same time, there are no means we can employ to procure a 
copious evacuation of serous fluids with greater certainty 
than the operation of purgatives, and it is upon these ac- 
counts that purging is the evacuation which has been most 
frequently, and perhaps with most success, employed in 
dropsy. It has been generally found necessary to employ 
purgatives of the more drastic kind ; which are commonly 

• H«w does this last a^rec with the first sen'.ence ot' this article; 



532 PRACTICE OF PHYSIC. 

known, and need not to be enumerated here.* I believe, 
indeed, that the more drastic purgatives are the most effec- 
tual for exciting absorption, as their stimulus is most rea- 
dily communicated to the other parts of the system ; but of 
late an opinion has prevailed, that some milder purgatives 
may be employed with advantage. This opinion has pre- 
vailed particularly with regard to the crystals vulgarly 
called the Cream of Tartar, which in large doses, fre- 
quently repeated, have sometimes answered the purpose 
of exciting large evacuations both by stool and urine, and 
has thereby cured dropsies. This medicine, however, has 
frequently failed, both in its operation and effects, when 
the drastic purgatives have been more successful. 

Practitioners have long ago observed, that in the em- 
ployment of purgatives, it is requisite they be repeated af- 
ter as short intervals as the patient can bear ; probably for 
this reason, that when the purging is not carried to the de- 
gree of soon exciting an absorption, the evacuation weak- 
ens the system, and thereby increases the afflux of fluids 
to the hydropic parts. 

1685.] The kidneys afford a natural outlet for a great 
part of the watery fluids contained in the blood-vessels ; and 
the increasing the excretion by the kidneys to a considera- 
ble degree, is a means as likely as any other of exciting an 
absorption in dropsical parts. It is upon this account that 
diuretic medicines have been always properly employed in 

•The Drastic purgatives are Jalap, Colocynth, Gamboge, Scammony, &c. Their drastic 
quality however depends very much on the dose in which they are given, small doses being 
gently laxaiivc, while large ones are very viulent in their operation They ought seldom to be 
given alone, but in conjunction with some aromatic, which greatly increases their action, and 
at the same time prevents the uneasiness of griping, with which their operation is frequently 
attended: most of thes ■ drastic* being resinous substances, they are difficultly soluble in the 
alimentary canal, or if reduced to a powder they are liable to concrete; in either case their 
action is impeded To remedy these inconveniences, it is usual to add to them some salt, which 
both divides the resin and prevents its concretion ; and consequently increases its action. For 
these reasons, we find in the shops many formulas, in which the drastic resins are mixed with 
either salts or aromatic.s, or both : as, the Pulvis Aloeticus, Pulvis e Scammonio compositus, Pul- 
vis e Scammonio cuui Aloe, Pulvis e senna compositus, and Electuarium e Scammonio of the 
London Pharmacopoeia; and, the Pulvis e Jalappa compositus, Pulvis e Scammonio compositus, 
Pilulae Aloetica?, Pilulae ex colotj nthide cum Aloe, Pilulae e Jalappa, and Pilulae Rufj of the 
Edinburgh Pharmacopoeia. 

Any of tht; fores;oin» compositions, if given in sufficient doses, are very active and brisk 
purges. Many more might be contrived, and on some occasions may be necessary. For pro- 
curing a brisk discharge of fluids, an addition of Calomel is remarkably efficacious as in the fol- 
lowing formula: 

R. Scammon. 
Calomel. 
Crem. Tart. 
Zinzib aa. p. x. 
M. f. Pulv. 

The dose of this powder is two scruples or a drachm, it is extremely active and ought to be 
used with care, the patients being kept moderately wjrui, and drinking some thin mucilaginous 
liquor during its opernion. 



PRACTICE OF PHYSIC. 533 

tlie cure of dropsy. The various diuretics that may be em. 
ployed, are enumerated in every treatise of the Materia 
Medica and of the Practice of Physic, and therefore need, 
not be repeated here. It happens, however, unluckily, that 
none of them are of very certain operation ; neither is it 
well known wby they sometimes succeed, and why they so 
often fail ; nor why one medicine should prove of service 
when another does not. It has been generally the fault of 
writers upon the Practice of Physic, that they give us in- 
stances of cases in which certain medicines have proved ve- 
ry efficacious, but neglect to tell us in how many other in- 
stances the same have failed. 

1686.] It deserves to be particularly observed here, that 
there is hardly any diuretic more certainly powerful than a 
large quantity of common water taken in by drinking. I 
have indeed observed above in 1659, that a large quanti- 
of water, or of watery liquors, taken in by drinking, 
has sometimes proved a cause of dropsy ; and practi- 
tioners have been formerly so much afraid that watery li- 
quors taken in by drinking might run off into the dropsical 
places and increase the disease, that they have generally 
enjoined the abstaining, as much as possible, from such li- 
quors. Nay, it has been further asserted, that by avoiding 
this supply of exhalation, and by a total abstinence from 
drink, dropsies have been entirely cured. What conclu- 
sion is to be drawn from these facts, is however, very doubt- 
ful.. A dropsy arising from a large quantity of liquids taken 
into the body, has been a very rare occurrence ; and there 
are, on the other hand, innumerable instances of very large 
quantities of water having been taken in and running off 
again very quickly by stool and urine, without producing 
any degree of dropsy. With respect to the total absti- 
nence from drink, it is a practice of the most difficult exe- 
cution ; and therefore has been so seldom practised, that 
we cannot possibly know how far it might prove effectual. 
The practice of giving drink very sparingly, has indeed 
been often employed : »ut in a hundred instances I have seen 
it carried to a great length without any manifest advantage ; 
while, on the contrary, the practice of giving drink very 
largely has been found not only safe, but very often effect- 
ual in curing the disease. The ingenious and learned Dr. 
Millman has, in my opinion, been commendably employed 
in restoring the practice of giving large quantities of wate- 
ry liquors for the cure of dropsy. Not only from tlie in- 



534 PRACTICE OF PHYSIC. 

stances he mentions from his own practice, and from that 
of several eminent physicians in other parts of Europe, but 
also from many instances in the records of physic, of the 
good effects of drinking large quantities of mineral waters 
in the cure of dropsy, I can have no doubt of the practice 
recommended by Dr. Millman being very often extremely 
proper. I apprehend it to be especially adapted to those 
cases in which the cure is chiefly attempted by diuretics. It 
is very probable that these medicines can hardly be carried 
in any quantity to the kidneys without being accompanied 
with a large portion of water ; and the late frequent em- 
ployment of the crystals of tartar has often shown, that the 
diuretic effects of that medicine are almost only remarkable 
when accompanied with a large quantity of water ; and 
that without this, the diuretic effects of the medicine sel- 
dom appear. 

I shall conclude this subject with observing, that as there 
are so many cases of dropsy absolutely incurable, the prac- 
tice now under consideration may often fail, yet in most 
cases it may be safely tried ; and if it appear that the water 
taken in passes readily by the urinary secretion, and espe- 
cially that it increases the urine beyond the quantity of drink 
taken in, the practice may probably be continued with great 
advantage : but, on the contrary, if the urine be not increas- 
ed, or be not even in proportion to the drink taken in, it 
may be concluded, that the water thrown in runs off by the 
exhalants, and will augment the disease. 

1687.] Another set of remedies which may be employed 
for exciting a serous excretion, and thereby curing dropsy, 
is that of sudorifics. Such remedies, indeed, have been 
sometimes employed : but however useful they may have 
been thought, there are few accounts of their having effect- 
ed a cure; and although I have had some examples of their 
success, in most instances of their trial they have been inef- 
fectual. 

Upon this subject it is proper to take notice of the several 
means that have been proposed and employed for dissi- 
pating the humidity of the body ; and particularly that of 
heat externally applied to the surface of it. Of such appli- 
cations I have had no experience ; and their propriety and 
utility must rest upon the credit of the authors who relate 
them. I shall offer only this conjecture upon the subject : 
that if such measures have been truly useful, as it has sel- 
dom been by the drawing, out of any sensible humidity, it 



PRACTICE OF PHYSIC. 535 

has probably been by their restoring the perspiration, which 
is so often greatly diminished in this disease ; or, perhaps, 
by changing the state of the skin, from the imbibing condi- 
tion which is alledged to take place, into that of perspiring. 

1688.] When, by the several means now mentioned, 
we shall have succeeded in evacuating the water of drop- 
sies, there will then especially be occasion for our third in- 
dication ; which is, to restore the tone of the system, the 
loss of which is so often the cause of the disease. This 
indication, indeed, may properly have place from the ve- 
ry first appearance of the disease ; and certain measures 
adapted to this purpose may, upon such first appearance, 
be employed with advantage. In many cases of a mode- 
rate disease, I am persuaded that they may obviate any 
future increase of it. 

1689.] Thus, upon what is commonly the first symp- 
tom of anasarca, that is, upon the appearance of what 
are called Oedematous Swellings of the feet and legs, the 
three remedies of bandaging, friction, and exercise, have 
often been used with advantage. 

1690.] That some degree of external compression is 
suited to support the tone of the vessels, and particularly 
to prevent the effects of the weight of the blood in dilating 
those of the lower extremities, must be sufficiently evident ; 
and the giving that compression by a bandage properly ap- 
plied, has been often useful. In applying such a bandage, 
care is to be taken that the compression may never be great- 
er on the upper than on the lower part of the limb ; and 
this, I think, can hardly ever be so certainly avoided, as 
by employing a properly constructed laced stocking. 

1691.] Friction is another means by which the action 
of the blood-vessels may be promoted, and thereby the 
stagnation of fluids in their extremities prevented. Ac- 
cordingly, the use of the flesh-brush has often contributed 
to discuss oedematous swellings. It appears to me, that 
friction, for the purposes now mentioned, is more properly 
employed in the morning, when the swelling is very much 
gone off, than in the evening, when any considerable de- 
gree of it has already come on. I apprehend also, that 
friction being made from below upwards only, is more use- 
ful than when made alternately upwards and downwards. 
It has been common, instead of employing the flesh-brush, 
to make friction by warm and dry flannels ; and this may 
in some cases be the most convenient : but I cannot perceive 



536 PRACTICE OF PHYSIC. 

that the impregnation of these flannels with certain dry 
fumes is of any benefit. 

1692] With respect to exercise, I must observe, that 
although persons being much in an erect posture during the 
day, may seem to increase the swelling which comes on 
at night ; yet as the action of the muscles has a great 
share in promoting the motion of the venous blood, so I 
am certain, that as much exercise in walking as the pa- 
tient can easily bear, will often prevent that oedometous 
swelling, which much standing, and even sitting, would 
have brought on. 

1693.] These measures, however, although they maybe 
useful at the coming on of a dropsy, whose causes are not 
very powerful, will be often insufficient in a more violent 
disease ; and such therefore will require more powerful 
remedies. These are, exercise and tonic medicines ; which 
may be employed both during the course of the disease 
and especially after the water has been evacuated. 

1694.] Exercise is suited to assist in every function of 
the animal ceconomy, particularly to promote perspiration, 
and thereby prevent the accumulation of watery fluids in 
the body. I apprehend also, that it may be the most ef- 
fectual means for preventing the skin from being in an im- 
bibing state ; and, as it has been hinted above on the subject 
of Emaciation (1608.) I am persuaded, that a full and 
large perspiration will always be a means of exciting ab- 
sorption in every part of the system. Exercise, therefore, 
promises to be highly useful in dropsy ; and any mode of 
it may be employed that the patient can most conveniently 
admit of. It should, however, always be as much as he 
can easily bear : and in anasarca, the share which the ex- 
ercise of muscles has in promoting the motion of the ve- 
nous blood, induces me to think that bodily exercise, to 
whatever degree the patient can bear it, will always be 
the most useful. From some experience also, I am per- 
suaded, that by exercise alone, employed early in the dis- 
ease, many dropsies may be cured. 

1695.] Besides exercise, various tonic remedies are pro- 
perly employed to restore the tone of the system. The chief 
of these are, chalybeates, the Peruvian bark, and various 
bitters. These are not only suited to restore the tone of the 
system in general, but are particularly useful in strength- 
ening the organs of digestion, Avhich in dropsies are fre- 



PRACTICE OF PHYSIC. 537 

quently very much weakened ; and for the same purpose 
also aromatics may be frequently joined with the tonics. 

J 696. J Cold bathing is upon many occasions the most 
powerful tonic we can employ ; but at the beginning of 
dropsy, when the debility of the system is considerable, it 
can hardly be attempted with safety. After, however, the 
water of dropsies has been very fully evacuated, and the 
indication is to strengthen the system for preventing a re- 
lapse, cold bathing may perhaps have a place. It is, at 
the same time, to be admitted with caution ; and can 
scarcely be employed till the system has otherwise reco- 
vered a good deal of vigor. When that indeed has hap- 
pened, cold bathing may be very useful in confirming and 
completing it. 

1697. J In persons recovering from dropsy, while the se- 
veral means now mentioned for strengthening the system 
are employed, it will be proper at the same time to keep 
constantly in view the support of the watery excretions ; 
and consequently the keeping up the perspiration by a great 
deal of exercise, and continuing the full flow of the uri- 
nary excretions by the frequent use of diuretics. 



SECTION II. 

Of the Hydrothorax or Dropsy of the Breast. 

1698.] THE preternatural collection of serous fluid in 
the thorax, to which we give the appellation of Hydro- 
thorax, occurs more frequently than has been imagined. 
Its presence, however, is not always to be very certainly 
known ; and it often takes place to a considerable degree 
before it be discovered. 

1699.] These collections of watery fluids in the thorax, 
are found in different situations. Very often the water is 
found at the same time in both sacs of the pleura, but fre- 
quently in one of them only. Sometimes it is found in 
the pericardium alone ; but for the most part it only ap- 
pears there when at the same time a collection is present in 
one or both cavities of the thorax. In some instances, the 
collection is found to be only in that cellular texture of the 
lungs, which surrounds the bronchiae, without there being 
at the same time any effusion into the cavity of the thorax. 

Pretty frequently the water collected consists chief! v of 

3z 



538 PRACTICE OF PHYSIC. 

a great number of hydatides in different situations : some- 
times seemingly floating in the cavity, but frequently 
connected with and attached to particular parts of the in- 
ternal surface of the pleura. 

1700.] From the collection of water being thus in vari- 
ous situations and circumstances, symptoms arise which 
are different in different cases ; and from thence it be- 
comes often difficult to ascertain the presence and nature 
of the affection. I shall, however, endeavor here to point 
out the most common symptoms, and especially those of 
that principal and most frequent form of the disease, when. 
the serous fluid is present in both sacs of the pleura, or, as 
we usually speak, in both cavities of the thorax. 

1701.] The disease frequently comes on with a sense of 
anxiety about the lower part of the sternum. This, before 
it has subsisted long, comes to be joined with some diffi- 
culty of breathing ; which at first appears only upon the 
person's moving a little faster than usual, upon his walk- 
ing up an acclivity, or upon his ascending a staircase : but 
after some time, this difficulty of breathing becomes more 
constant and considerable, especially during the night, 
when the body is in a horizontal situation. Commonly, at 
the same time, lying upon one side is more easy than upon 
the other, or perhaps lying upon the back more easy than 
upon either side. These circumstances are usually attend- 
ed with a frequent cough, that is at first dry ; but which, 
after some time, is accompanied with an expectoration of 
thin mucus. 

With all these symptoms, the hydrothorax is not certain- 
ly discovered, as the same symptoms often attend other dis- 
eases of the breast. When however, along with these symp- 
toms there is at the same time an oedematous swelling of the 
feet and legs, a leucophlegmatic paleness of the face, and a 
scarcity of urine, the existence of a hydrothorax can be no 
longer doubtful. Some writers have told us, that sometimes 
in this disease, before the swelling of the feet comes on, a 
watery swelling of the scrotum appears ; but I have never 
met with any instance of this. 

1702.] Whilst the presence of the disease is somewhat 
uncertain, there is a symptom Avhich sometimes take? place, 
and has been thought to be a certain characteristic of it ; 
and that is, when soon after the patient has fallen asleep, he 
is suddenly awaked with a sense of anxiety and difficult 
breathing, and with a violent palpitation of the heart. These 



PRACTICE OF PHYSIC. 53* 

feelings immediately require an erect posture ; and very of- 
ten the difficulty of breathing continues to require and to 
prevent sleep for a great part of the night. This symptom 
I have frequently found attending the disease : but I have 
also met with several instances in which this symptom did 
not appear. I must remark further, that I have not found 
this symptom attending the empyema, or any other disease 
of the thorax ; and therefore, when it attends a difficulty 
of breathing, accompanied with any the smallest symptom 
pf dropsy, I have had no doubt in concluding the presence 
of water in the chest, and have always had my judgment 
confirmed by the symptoms which afterwards appeared. 

1703.] The hydrothurax often occurs with very few, or 
almost none, of the symptoms above mentioned ; and is 
not, therefore, very certainly discovered till some others 
appear. The most decisive symptom is a fluctuation of 
water in the chest, perceived by the patient himself, or by 
the physician, upon certain motions of the body. How far 
the method proposed by Auenbrugger will apply to ascer- 
tain the presence of water and the quantity of it in the chest, 
I have not had occasion or opportunity to observe. 

It has been said, that in this disease some tumor appears 
upon the sides or upon the back, but I have not met with 
any instance of this. In one instance of the disease, I found 
one side of the thorax considerably enlarged, the ribs stand- 
ing out farther on that side than upon the other. 

A numbness and a degree of palsy in one or both arms,, 
has been frequently observed to attend a hydrothorax. 

Soon after this disease has made some progress, the pulse 
commonly becomes irregular, and frequently intermitting : 
but this happens in so many other diseases of the breast, that, 
unless when it is attended with some other of the above- 
mentioned symptoms, it cannot be considered as denoting 
the hydrothorax. 

1704.] This disease, as other dropsies, is commonly at- 
tended with thirst and a scarcity of urine, to be explained 
in the same manner as in the case of anasarca. (1674.) The 
hydrothorax, however, is sometimes w ithout thirst, or any 
other febrile symptom ; although I believe this happens in 
the case of partial affections only, or when a more general 
affection is yet but in a slight degree. In both cases, how- 
ever, and more especially when the disease is considerably 
advanced, some degree of fever is generally present : and I 
apprehend it to be in such case, that the persons affected are 



540 PRACTICE OF PHYSIC. 

more than usually sensible to cold, and complain of the cold- 
ness of the air when that is not perceived by other persons. 

1705.] The hydrothorax sometimes appears alone, with- 
out any other species of dropsy being: present at the same 
time : and in this case the disease, for the most part, is a 
partial affection, as being either of one side of the thorax 
only, or being a collection of hydatides in one part of the 
chest. The hydrothorax, however, is very often a part of 
more universal dropsy, and when at the same time there is 
water in all the three principal cavities and in the cellular 
texture of a great part of the body. I have met with se- 
veral instances in which such universal dropsy began first by 
an effusion into the thorax. The hydrothorax, however, 
more frequently comes on from an anasarca gradually in- 
creasing ; and, as I have said above, the general diathesis 
seems often to affect the thorax sooner than it does either the 
head or the abdomen. 

1706.] This disease seldom admits of a cure, or even of 
alleviation, from remedies. It commonly proceeds to give 
more and more difficulty of breathing, till the action of the 
lungs be entirely interrupted by the quantity of water ef- 
fused ; and the fatal event frequently happens more sud- 
denly than was expected. In many of the instances of a 
fatal hydrohorax, I have remarked a spitting of blood to 
come on several days before the patient died. 

1 707.] The cause of hydrothorax is often manifestly one 
or other of the general causes of dropsy pointed out above : 
but what it is that determines these general causes to act 
more especially in the thorax, and particularly what it is 
that produces the partial collections that occur there, I do 
not find to be easily ascertained. 

1708.] From what has been said above, it will be evident, 
that the cure of hydrothorax must be very much the same 
with that of anasarca ; and when the former is joined with 
the latter as an effect of the same general diathesis, there 
can be no doubt of the method of cure being the same in 
both. Even when the hydrothorax is alone, and the disease 
partial, from particular causes acting in the thorax only, 
there can hardly be any other measures employed, than the 
general ones proposed above. There is only one particular 
measure adapted to the hydrothorax ; and that is, the 
drawing off the accumulated waters by a paracentesis of 
the thorax. 

1709.] To what cases this operation may be most pro- 



PRACTICE OF PHYSIC. 541 

perly adapted, I find it difficult to determine. That it 
may be executed with safety, there is no doubt ; and that 
it has been sometimes practised with success, seems to be 
very well vouched.* When the disease depends upon a 
general hydropic diathesis, it cannot alone prove a cure, 
but may give a temporary relief ; and when other remedies 
*eem to be employed with advantage, the drawing off the 
water may very much favor a complete cure. I have not, 
however, been so fortunate as to see it practised with any 
success ; and even where it was most promising, that is, 
in cases of partial affection, my expectations have been 
disappointed from it. 



SECTION III. 
Of Ascites, or Dropsy of the Lower Belly. 

1710.] THE name of Ascites is given to every collec- 
tion of waters causing a general swelling and distention of 
the lower belly ; and such collections are more frequent than 
those which happen in the thorax. 

1711.] The collections in the lower belly, like those of 
the thorax, are found in different situations. Most com- 
monly they are in the sac of the peritonaeum, or general 
cavity of the abdomen : but they often begin by sacs form- 
ed upon, and connected with one or other of the viscera ; 
and perhaps the most frequent instances of this kind occur 
in the ovaria of females. Sometimes the water of ascites 
is found entirely without the peritonaeum, and between this 
and the abdominal muscles. 

1712.] These collections connected with particular vis- 
cera, and those formed without the peritonaeum, form that 
disease which authors have termed the encysted dropsy, or 
hydrops saccatus. Their precise seat, and even their exist- 

• In the memoirs of the Academy of Sciences at Taris, for 1703, M. Du Verney relates the case 
of a woman who had both an Ascites and Hydrothorax. He first emptied the abdomen by tap- 
ping, and a few days afterwards he pierced the thorax with a trochar, near to the spine, between 
the second and third false ribs; by which opening he drew off a considerable quantity of wa- 
ter : the operation gave immediate relief to the patient, and she was able to return to her ordi- 
nary employments in about a month's time. — Bianchi also relates a successful operation of tap- 
ping the thorax ; but he seems to be timid in his practice, and confesses that he lias seldom ven- 
tured on the operation. The practice of evacuating water contained in the thorax by an inci- 
sion is very old. We find it recommended by Hippocrates, with particular directions for per- 
forming the operation, in his second book on diseases. See the Geneva edition ot Fuesius' 
Hippocrates, pag. 483.— That the practice was frequently attended with success, in those early 
lurficiently evident by the context ; for Hippocrates, alter describing the operation, and 
tin' subsequent management of the patient, says, •' If pus appear on the plaster covering the 
'• wound on the nfth'day after the operation, the patient generally recovers ; it «ot, he is seized 



•rift a cough and thirst, and dies 



542 PRACTICE OF PHVSIC. 

ence, is very often difficult to be ascertained. They are ge- 
nerally formed by collections of hydatides. 

1713.] In the most ordinary case, that of abdominal drop- 
sy, the swelling at first is in some measure over the whole 
belly, but generally appears most considerable in the epi- 
gastrium. As the disease, however, advances, the swelling 
becomes more uniform over the whole. The distention, and 
sense of weight, though considerable, vary a little accord- 
ing as the posture of the body is changed ; the weight being 
felt the most upon the side on which the patient lies, while 
at the same time on the opposite side the distention becomes 
somewhat less. In almost all the instances of ascites, the 
fluctuation of the water within, may be perceived by the 
practitioner's feeling, and sometimes by his hearing. This 
perception of fluctuation does not certainly distinguish the 
different states of dropsy ; but serves very well to distinguish 
dropsy from tympanites, from cases of physconia, and from 
the state of pregnancy in women. 

1714.] An ascites frequently occurs when no other spe- 
cies of dropsy does at the same time appear ; but sometimes 
the ascites is a part only of universal dropsy. In this case, 
it usually comes on in consequence of an anasarca, gradu- 
ally increasing ; but its being joined with anasarca, does 
not always denote any general diathesis, as for the most part 
an ascites sooner or later occasions oedematous swellings of 
the lower extremities. When the collection of water in the 
abdomen, from whatever cause, becomes considerable, it is 
always attended with a difficulty of breathing ; but this 
symptom occurs often when, at the same time, there is no 
water in the thorax. The ascites is sometimes unaccompa- 
nied with any fever ; but frequently there is more or less of 
fever present with it. The disease is never considerable, 
without being attended with thirst and a scarcity of urine. 

1715.] In the diagnosis of ascites, the greatest difficultv 
that occurs, is in discerning when the water is in the cavity 
of the abdomen, or when it is in the different states of en- 
cysted dropsy above-mentioned. There is, perhaps, no cer- 
tain means of ascertaining this in all cases; but in many we 
may attempt to form some judgment with regard to it. 

When the antecedent circumstances give suspicion of a 
general hydropic diathesis ; when^t the same time some de- 
gree of dropsy appears in other parts of the body ; and 
when, from its first appearance, the swelling has been equal- 
ly over the whole belly, we may generally presume that the 



PRACTICE OF PHYSIC. 543 

water is in the cavity of the abdomen. But when an as- 
cites has not been preceded by any remarkably cachectic 
state of the system, and when at its beginning the tumor 
and tension had appeared in one part of the belly more than 
another, there is reason to suspect an encysted dropsy. 
Even when the tension and tumor of the belly have become 
general and uniform over the whole ; yet if the system of 
the body in general appear to be little affected ; if the pa- 
tient's strength be little impaired ; if the appetite continue 
pretty entire, and the natural sleep be little interrupted ; if 
the menses in females continue to flow as usual ; if there be 
yet no anasarca ; or, though it may have already taken 
place, if it be still confined to the lower extremities, and 
there be no leucophlegmatic paleness or sallow color in the 
countenance ; if there be no fever, nor so much thirst, or 
Scarcity of urine, as occur in a more general affection ; then, 
according as more of these different circumstances take 
place, there will be the stronger ground for supposing the 
ascites to be of the encysted kind. 

The chief exception to be made from this as a general 
rule, will, in my opinion, be when the ascites may with 
much probability, be presumed to have come on in conse- 
quence of a scirrhous liver ; which, I apprehend, may oc- 
casion a collection of water in the cavity of the abdomen, 
while the general system of the body may not be otherwise 
much affected. 

1716.] With respect to the cure of ascites when of the 
encysted kind, it does not, so far as I know, admit of any. 
When the collection of water is in the abdominal cavity 
alone, without any other species of dropsy present at the 
same time, 1 apprehend the ascites will always be of diffi- 
cult cure ; for it may be presumed to depend upon a scir- 
rhosity of the liver, or other considerable affection of the 
abdominal viscera, which I conceive to be of very difficult 
cure, and therefore the ascites depending upon them. At 
the same time, such cases may often admit of a temporary 
relief by the paracentesis. 

17 17.] When the ascites is a part of universal dropsy, 
it may, as far as other cases of that kind can, admit ot 
cure ;' and it will be obvious, that such a cure must be ob- 
tained by the same means as above proposed for the cure 
of general anasarca.* 

It frequently happens, that the ascites is attended with 

*See the notes an article 168* 



$44 PRACTICE OF PHYSIC. 

a diarrhoea; and, in that case, does not admit of the use 
of purgatives so freely as cases of anasarca commonly do. 
It is therefore often to be treated by diuretics almost alone. 

The diuretics that may be employed, are chiefly those 
above-mentioned ; but in ascites, a peculiar one has been 
found out. It is a long continued gentle friction of the 
skin over the whole of the abdomen, by the fingers dipped 
in oil. This has sometimes been useful in exciting an in- 
creased flow of urine ; but in most of the trials of it which 
I have known made, it has failed in producing that effect. 

1718.] The ascites admits of a particular means for im- 
mediately drawing off the collected waters : and that is the 
well-known operation of the paracentesis of the abdomen. 
In what circumstances of ascites this operation can most 
properly be proposed, it is difficult to determine ; but, so 
far as I can judge, it must be regulated by very much the 
same considerations as those above-mentioned with regard 
to the paracentesis of the thorax. 

The manner of performing the paracentesis of the abdo- 
men, and the precautions to be taken with respect to it, 
are now so commonly known, and delivered in so many 
books, that it is altogether unnecessary for me to offer any 
directions upon that subject here; especially after the full 
and judicious information and directions given by Mr. 
Bell, in the second volume of his System of Surgery. 



CHAPTER IV. 

OF GENERAL SWELLINGS, ARISING FROM 

AN INCREASED BULK OF THE WHOLE 

SUBSTANCE OF PARTICULAR PARTS. 

1719.] T TPON the subjects of this chapter, several 
vJ nosological difficulties occur, and particu- 
larly with respect to admitting the Physconia into the order 
of General Swellings. At present, however, it is not neces- 
sary for me to discuss this point, as I am here to omit en- 
tirely the consideration of Physconia ; both because it can 
seldom admit of any successful practice, and because I can- 
not deliver any thing useful either with regard to the patho- 
logy or practice in such a disease. 

1720.] The only other genus of disease comprehended 
under the title of the present chapter, is the Rachitis ; and 



PRACTICE OF PHYSIC. S45 

this being both a proper example of the class of Cachexy, 
and of the order of Intumescentiee or General Swellings, I 
shall offer some observations with regard to it. 



Of RACHITIS, or RICKETS. 

1721.] THIS disease has been supposed to have appear- 
ed only in modern times, and not above two hundred years 
ago. This opinion, notwithstanding it has been maintained 
by persons of the most respectable authority,* appears to 
me, from many considerations, improbable ; but it is a 
point of too little consequence to detain my readers here. 
The only application of it which deserves any notice is, 
that it has led to a notion of the disease having arisen from 
the lues venerea, which had certainly made its first appear- 
ance in Europe not very long before the date commonly 
assigned for the appearance of rachitis : but I shall hereaf- 
ter show, that the supposed connection between the Siphy- 
lis and Rachitis is without foundation. f 

1722.] In delivering the history of the Rickets, I must, 
in the first place, observe that with respect to the antece- 
dents of the disease, every thing to be found in authors up- 
on this subject, appears to me to rest upon a very uncertain 
foundation. In particular, with respect to the state of 
the parents whose offspring become affected with this disease, 
J have met with many instances of it, in children from seem- 
ingly healthy parents, and have met likewise with many in- 
stances of children who never became affected with it, al- 
though born of parents who, according to the common ac- 
counts, should have produced a rickety offspring: so that 
even making allowance for the uncertainty of fathers, I do 
not find the general opinion of authors upon this subject to 
be properly supported. 

1723.] The disease, however, may be justly considered 
as proceeding from parents ; for it often appears in a great 
number of the same family : and my observation leads me 
to judge, that it originates more frequently from mothers 
than from fathers. So far as I can refer the disease of the 
children to the state of the parents, it has appeared to me 
most commonly to arise from some weakness, and pretty 
frequently from a scrophulous habit in the mother. To con- 

• Boerlnave was of this opinion. See Van Swieten*s Commentary on Aphoriim 1438, 
+ Sec artkic 17i!8. 

4a 



546 PRACTICE OF PHYSIC. 

elude the subject, I must remark, that in many cases I have 
hot been able to discern the condition of the parents, to 
which I could refer it. 

When nurses, other than the mothers, have been employ- 
ed to suckle children, it has been supposed that such nurses 
have frequently given occasion to the disease* and when 
nurses have both produced and have suckled children who 
became rickety, there may be ground to suspect their hav- 
ing occasioned the disease in the children of other persons : 
but I have had few opportunities of ascertaining this matter. 
It has in some measure appeared to me, that those nurses 
are most likely to produce this disease, who give infants 
a large quantity of very watery milk, and who continue to 
suckle them longer than the usual time. Upon the whole, 
however, I am of opinion, that hired nurses seldom occa- 
sion this disease, unless when a predisposition to it has pro- 
ceeded from the parents. 

1724.] With regard to the other antecedents, which have 
been usuallj' enumerated by authors as the remote causes of 
this disease, I judge the accounts given to be extremely fal- 
lacious ; and I am very much persuaded, that the circum- 
stances in the rearing of children, have less effect in pro- 
ducing rickets than has been imagined. It is indeed not 
unlikely, that some of these circumstances mentioned as re- 
mote causes may favor, while other circumstances may re- 
sist, the coming on of the disease ; but at the same time, I 
doubt if any of the former would produce it where there 
was no predisposition in the child's original constitution. 
This opinion of the remote causes, I have formed from ob- 
serving, that the disease comes on when none of these had 
been applied ; and more frequently that many of them had 
been applied without occasioning the disease. Thus the 
learned Zeviani alleges, that the disease is produced by an 
acid from the milk with which a child is fed for the first nine 
months of its life : but almost all children are fed with the 
same food, and in which also an acid is always produced ; 
while at the same time, not one in a thousand of the infants 
so fed becomes affected with the rickets. If, therefore, in 
the infants who become affected with this disease, a peculi- 
arly noxious acid is produced, we must seek for some pe- 
culiar cause of its production, either in the quality of the 
milk, or in the constitution of the child ; neither of which 

* This opinion was held by Boerhaave, and notwithstanding what the author says at the end of 
this paragraph/ the opinion is certainly founded on experience. 



PRACTICE OF PHYSIC. 5 4T 

however, Mr. Zeviani has explained. I cannot indeed be- 
lieve that the ordinary acid of milk has any share in produ- 
cing this disease, because I have known many instances of 
the acid being produced and occasioning various disorders, 
without, however, its ever producing rickets. 

Another of the remote causes commonly assigned is the 
child's being fed with unfermented farinaceous food. But 
over the whole world, children are fed with such farinacea, 
while the disease of rickets is a rare occurrence : and I have 
known many instances where children have been fed with a 
greater than usual proportion of fermented farinacea, and 
also a greater proportion of animal food, without these pre- 
venting the disease. In my apprehension, the like obser- 
vations might be made with respect to most of the circum- 
stances that have been mentioned as the remote causes of 
rickets. 

1725.] Having thus offered my opinion concerning the 
supposed antecedents of this disease, I proceed now to men- 
tion the phenomena occurring after it has actually come on.* 

The disease seldom appears before the ninth month, and 
seldom begins after the second year, of a child's age. In 
the interval between these periods, the appearance of the 
disease is sometimes sooner, sometimes later ; and common- 
ly at first the disease comes on slowly. The first appear- 
ances are, a flaccid ity of the flesh, the body at the same 
time becoming leaner, though food be taken in pretty large- 
ly. The head appears large with respect to the body ; 
with the fontanelle, and perhaps the sutures, more open 
than usual in children of the same age. The head conti- 
nues to grow larger ; in particular, the forehead becoming 
unusually prominent ; and at the same time the neck con- 
tinues slender, or seems to be more so, in proportion to 
the head. The dentition is slow, or much later than usual ; 
and those teeth which come out, readily become black, 
and frequently again fall out. The ribs lose their convex- 
ity, and become flattened on the side ; while the sternum 
is pushed outward, and forms a sort of ridge. At the same 
time, or perhaps sooner, the epiphyses at the several joints 
of the limbs become swelled ; while the limbs between the 
joints appear, or perhaps actually become, more slender. 
The bones seem to be every where flexible, becoming va- 
riously distorted ; and particularly the spine of the back be- 

• Thi» admirable description of the disease merits the peculiar antmieu »f \i» roung practi- 
tioner. 



54S PRACTICE OF PHYSIC. 

coming incurvated in different parts of its length. If thechild, 
at the same time the disease comes on, had acquired the 
power of walking, it becomes daily more feeble in its mo- 
tions, and more averse to the exertion of them, losing at 
length the power of walking altogether. Whilst these symp- 
toms go on increasing, the abdomen is always full, and pre- 
ternaturally tumid. The appetite is often good, but the 
stools are generally frequent and loose. Sometimes the fa* 
culties of the mind are impaired, and stupidity or fatuity 
prevails ; but commonly a premature sensibility appears, and 
they acquire the faculty of speech sooner than usual. At 
the first coming on of the disease, there is generally no fever 
attending it : but it seldom continues long, till a frequent 
pulse, and other febrile symptoms, come to be constantly- 
present. With these symptoms the disease proceeds, and 
continues in some instances for some years ; but very often, 
in the course of that time, the disease ceases to advance, 
and the health is entirely established, except that the dis- 
torted limbs, produced during the disease, continue for the 
rest of life. In other cases, however, the disease proceeds 
increasing, till it has affected almost every function of the 
animal oeconomy, and at length terminates in death. The 
variety of symptoms which in such cases appear, it does 
not seem necessary to enumerate, as they are not essential 
to the constitution of the disease, but are merely conse- 
quences of the more violent conditions of it. In the bodies 
of those who have died, various morbid affections have been 
discovered in the internal parts. Most of the viscera of 
the abdomen have been found to be preternaturally enlarg- 
ed. The lungs have also been found in a morbid state,, 
seemingly from some inflammation that had come on to- 
wards the end of the disease. The brain has been com- 
monly found in a flaccid state, with effusions of a serous 
fluid into its cavities. Very universally the bones have 
been found very soft, and so much softened as to be readily 
cut by a knife. The fluids have been always found in a dis- 
solved state, and the muscular parts very soft and tender ; 
and the whole of the dead body without any degree of that 
rigidity which is so common in almost all others. 

1726.] From these circumstances of the disease, it seems 
to consist in a deficiency of that matter which should form 
the solid parts of the body. This especially appears in the 
faulty state of ossification, seemingly depending upon the 
deficiency of that matter which should be deposited in the 



PRACTICE OF PHYSIC. 54* 

membranes which are destined to become bony, and should 
give them their due rirmness and bony hardness. It appear* 
that this matter is not supplied in due quantity ; but that 
in place of it, a matter fitted to increase their bulk, parti- 
cularly in the epiphyses, is applied too largely. What this 
deficiency of matter depends upon, is difficult to be ascer- 
tained. It mav be a fault in the organs of digestion and as- 
similation, which prevents the fluids in general from being 
properly prepared : or it may be a fault in the organs of 
nutrition, which prevents the secretion of a proper matter 
to be applied. With respect to the latter, in what it may 
consist, I am entirely ignorant, and cannot even discern 
that such a condition exists: but the former cause, both in 
its nature and existence, is more readily perceived ; and it 
is probable that it has a considerable influence iu the mat- 
ter ; as in rachitic persons a thinner state of the blood, both 
during life and after death, so commonly appears. It is 
this state of the fluids, or a deficiency of bony matter in 
them, that I consider as the proximate cause of the disease; 
and which again may in some measure depend upon a ge- 
neral laxity and debility of the moving fibres of the organs 
that perform the functions of digestion and assimilation. 

1727.] There is, however, something still wanting to ex- 
plain, why these circumstances discover themselves at a 
particular time of life, and hardly ever either before or after 
a certain period ; and as to this I would offer the following 
conjectures. Nature having intended that human life should 
proceed in a certain manner, and that certain functions 
should be exercised at a certain period of life only ; so it has 
generally provided, that at that period, and not sooner, the 
body should be fitted for the exercise of the functions suit- 
ed to it. To apply this to our present subject, Nature 
seems to have intended that children should walk only at 
twelve months old ; and accordingly has provided that a- 
gainst that age, and no sooner, a matter should be prepared 
fit to give thar firmness to the bones which is necessary tci 
prevent their oending too easily under the weight of the 
body. Nature, however, is not always steady and exact 
in executing her own purposes ; and if therefore the prepa- 
ration of bony matter shall not have been made against the 
time there is a particular occasion for it, the disease of 
rickets, that is, of soft and flexible bones, must come on ; 
and will discover itself about the particular period we have 
mentioned. Further, it will be equally probable, that if at 



550 PRACTICE OF PHYSIC. 

the period mentioned, the bones shall have acquired their 
due firmness, and that nature goes on in preparing and 
supplying the proper bony matter, it may be presumed, 
that against the time a child is two years old, such a quan- 
tity of bony manner will be applied, as to prevent the bones 
from becoming again soft and flexible during the rest of 
life ; unless it happen, as indeed it sometimes does, that 
certain causes occur to wash out again the bony matter from 
the membranes in which it had been deposited. The ac- 
count I have now given of the period at which the rickets 
occur, seems to confirm the opinion of its proximate cause 
being a deficiency of bony matter in the fluids of the body. 

1728.] It has been frequently supposed, that a siphylitic 
taint has a share in producing rickets ; but such a supposi- 
tion is altogether improbable. If our opinion of the rickets 
having existed in Europe before the siphylis was brought 
into it, be well founded, it will then be certain that the dis- 
ease may be occasioned without any siphylitic acrimony 
having a share in its production. But further, when a si- 
phylitic acrimony is transmitted from the parent to the off- 
spring, the s3*mptoms do not appear at a particular time of 
life only, and commonly more early than the period of 
rickets ; the symptoms also are very different from those 
of rickets, and unaccompanied with any appearance of the 
latter ; and, lastly, the symptoms of siphylis are cured by 
means which, in the case of rickets, have either no effect, 
or a bad one. It may indeed possibly happen, that siphy- 
lis and rickets may appear in the same person; but it is 
to be considered as an accidental complication : arid the 
very few instances of it that have occurred, are by no 
means sufficient to establish any necessary connection be- 
tween the two diseases. 

1729.] With respect to the deficiency of bony matter, 
which I consider as the proximate cause of rickets, some 
further conjectures might be offered concerning its remote 
causes ; but none of them appear to me very satisfying ; 
and whatever they might be, it appears to me they must 
again be resolved into the supposition of a general laxity 
and debility of the system. 

1730.] It is upon this supposition almost alone that the 
cure of rickets has entirely proceeded. The remedies have 
been such especially as were suited to improve the tone of 
the system in general, or of the stomach in particular : and 
we know that the latter are not only suited to improve the 



PRACTICE OF PHYSIC. 551 

tone of the stomach itself, but by that means to improve 
also the tone of the whole system. 

1731.] Of tonic remedies, one of the most promising 
seems to have been cold bathing ; and I have found it the 
most powerful in preventing the disease. For a long time 
past, it has been the practice in this country, with people 
of all ranks, to wash their children from the time of their 
birth with cold water ; and from the time that children are 
a month old, it has been the practice with people of better 
rank to have them dipped entirely in cold water every morn- 
ing : and wherever this practice has been pursued, I have 
not met with any instance of rickets. Amongst our com- 
mon people, although they wash their children with cold 
water only, yet they do not so commonly practise immer- 
sion : and when amongst these I meet with instances of 
rickets, I prescribe cold bathing ; which accordingly has 
often checked the progress of the disease, and sometimes 
seems to have cured it entirely. 

1732.] The remedy of Ens Veneris, recommended by 
Mr. Boyle, and since his time very universally employed, 
is to be considered as entirely a tonic remedy. That or 
some other preparation of iron I have almost constantly em- 
ployed, though not indeed always with success. I have been 
persuaded, that the ens veneris of Mr. Boyle, notwithstand- 
ing his giving it this appellation, was truly a preparation of 
iron, and no other than what we now name the Flores Mar- 
tiales :* but it appears, that both Benevoli and Buchner 
have employed a preparation of copper ; and I am ready to 
believe it to be a more powerful tonic than the preparations 
of iron.f 

1733.] Upon the supposition of tonic remedies being 
proper in this disease, I have endeavored to employ the 
Peruvian bark : but from the difficulty of administering it 
to infants in any useful quantity, I have not been able to 
discover its efficacy ; but I am very ready to believe the tes- 
timony of De Haen upon this subject.^ 

• The dose of this medicine is from four to twenty grains, it must be siren in the form of a 
bolus. The young practitioner ought to beware of prescribing Flores inartiales in pills, which 
will swell and crumble to pieces if they are not composed of a considerable quantity of some 
gummi re»in. The Flores martiales may be very conveniently given in a tincture of proof spi- 
rit. Then U a formula of it in the last London Pharmacopoeia, under the name of Tlnctura 
lerri Ammoniacahs. The dose of it is a tea-spooniui in a wine glass of cold water, and it is j 
Tery elegant form of administering the chalybeates. 

+ topper is a very dangerous remedy, as was mentioned above in the notes on article 1337. 
The author had a very high opinion of copper as a tonic. 

t It is doubtless difficult to make children swallow a sufficient quantity of bark to produce any 
^ood effects, \et it is not impossible. The formula best adapted for children, is trie powder of 
the extract; but as it sometimes occasions constipation, this effect must be guarded against by 
some proper laxative, especially by Rhubarb given either with the bark or separately. The fol- 
lowing formula is a proper dose for a child of two yean old, (0 be repeated twice a day; 



552 PRACTICE OF PHYSIC. 

1 734.] Exercise, which is one of the most powerful tonics, 
Jias been properly recommended for the cure of rickets ; and 
as the exercise of gestation only can be employed, it should 
always be, with the child laid in a horizontal situation ; as 
the carrying them, or moving them in any degree of an 
erect posture, is very apt to occasion some distortion. It 
is extremely probable, that, in this disease, friction with 
dry flannels may be found an useful remedy. 

H35.] It is also sufficiently probable, that the avoiding 
of moisture is not only adviseable, but may likewise be of 
service in the cure of this disease. 

There is no doubt that a certain diet may contribute to 
the same end ; but what may be the most eligible, I dare 
not determine. I have no doubt that leavened bread may 
be more proper than unfermented farinacea ; but I cannot 
find any reason to believe that strong beer can. ever be a 
proper remedy. 

Practitioners have been divided in opinion concerning 
the use of milk in this disease. Zeviani, perhaps from theo- 
ry, condemns the use of it ; but Benevoli employed it 
without its impeding the cure of the disease. This last I 
have often remarked in the course of my own practice. 
As it is difficult to feed children entirely without milk ; so I 
fcave commonly admitted it as a part of the diet of rickety 
children ; and in many instances I can affirm, that it did 
not prevent the cure of the disease. In cases, how ever, 
of any appearance of rickets, and particularly of a slow 
dentition, I have dissuaded the continuance of a child up- 
on the breast ; because the milk of women is a more wa- 
tery nourishment than that of cows : and I have especially 
dissuaded the continuing a child upon the breast, when 1 
thought the nurse gave rather too much of such a watery 
nourishment ; for, as has been above-mentioned, 1 have had 
frequent occasion to suspect, that the milk of such nurses 
has a tendency to favor the coming on of the rickets.* 

1 736.] Besides the remedies and regimen now mention- 
ed, practitioners have commonly employed in this disease, 
both emetics and purgatives. When the appetite and di- 
gestion are considerably impaired, vomiting, if neither vio- 

R. Extr. Cort. Peruv. dur. gr. viii. 
Pulv. Rad. Rhej. gr. x. 
Sacch. Alb. gr. xv. 
M. f. Pulv. 

♦ flow does titit accord with the last sentence of article 1723; 



PRACTICE OF PHYSIC. 553 

lent, nor frequently repeated, seems to be of service ; and 
by a moderate agitation of the abdominal viscera, may in 
some measure obviate the stagnation and consequent swel- 
ling that usually occur in them. 

As the tumid state of the abdomen, so constantly to be 
met with in this disease, seems to depend very much upon 
a tympanitic affection of the intestines ; so, both by ob- 
viating this, and by deriving from the abdominal viscera, 
frequent gentle purgatives may be of service. Zeviani, 
perhaps properly, recommends in particular rhubarb ; 
which, besides its purgative quality, has those also of bit- 
ter and astringent. 

1737.] I have now mentioned most of the remedies com- 
monly employed by the practitioners of former times ; but 
I must not omit mentioning some others that have been 
lately suggested. The late Mr. De Haen recommends 
the testacea ; and assures us of their having been employed 
with success : but in the few trials which I have had occa- 
sion to make, their good effects did not appear. 

The late Baron Van Swieten gives us one instance of 
rickets cured by the use of hemlock : but I do not know 
that the practice has been repeated. 



BOOK III. 

OF THE IMPETIGINES ; OR DEPRAVED HA- 
BIT, WITH AFFECTIONS OF THE SKIN. 

1738.] T FIND it difficult to give any sufficiently cor- 
X rect and proper character of this order. The 
diseases comprehended under it, depend, for the most part, 
upon a depraved state of the whole of the fluids, producing 
tumors, eruptions, or other preternatural affections of the 
skin. Although it be extremely difficult to find a general cha- 
racter of the order that will apply to each of the genera and 
species, I shall treat of the principal genera which have 
been commonly comprehended under this order, and which 
I have enumerated in my Nosology. 

4» 



554 PRACTICE OF PHYSIC. 

CHAPTER I. 

OF SCROPHULA, OR THE KINGS EVIL. 

1739.] r T" , HE character of this disease I have atterppt- 
Jl ed in my Nosology : but it will be more 
properly taken from the whole of its history, now to be 
delivered. 

1740.] It is commonly, and very generally, a hereditary 
disease; and although it sometimes may, yet it rarely ap- 
pears, but in children whose parents had at some period 
of their lives been affected with it. Whether it may not 
fail to appear in the children of scrophulous parents, and 
discover itself afterwards in their offspring in the succeed- 
ing generation, I cannot certainly determine ; but believe 
that this has frequently happened. It appears to me to 
be derived more commonly from fathers than from mo- 
thers ; but whether this happens from their being more 
scrophulous men than scrophulous women married, I am 
not certain. 

With respect to the influence of parents in producing this 
disease, it deserves to be remarked, that in a family of 
many children, when one of the parents has been affected 
with scrophula, and the other not ; a.s it is usual for some of 
the children to be in constitution pretty exactly like the one 
parent, and others of them like the other; it commonly 
happens, that those children who most resemble the scro- 
phulous parent become affected with scrophula, while those 
resembling the other parent entirely escape. 

1741.] The scrophula generally appears at a particular 
period of life. It seldom appears in the first, or even in 
the second year of a child's life ; and most commonly it oc- 
curs from the second, or, as some alledge, and perhaps 
more properly, from the third, to the seventh year. Fre- 
quently, however, it discovers itself at a later period ; and 
there are instances of its first appearance, at every period 
till the age of puberty ; after which, however, the first 
appearance, of it is very rare. 

17±2.] When it does not occur very early, we can ge- 
nerally distinguish the habit of body peculiarly disposed to 
it. It most commonly affects children of soft and flaccid 
habits, of fair hair and blue eyes ; or at least affects those 
much more frequently than those of an opposite complexion. 



PRACTICE OF PHYSIC. S53 

It affects especially children of smooth skins and rosy cheeks ; 
and such children have frequently a tumid upper lip, with 
a chop in the middle of it ; and tfcis tumor is often consi- 
derable, and extended to the columna nasi and lower part 
of the nostrils. The disease is sometimes joined with, or 
follows rickets ; and although it frequently appears in chil- 
dren who have not had rickets in any great degree, yet it 
often attacks those who, by a protuberant forehead, by tu- 
mid joints, and a tumid abdomen, show that they had some 
rachitic disposition. In parents who without having had the 
disease themselves, seem to produce scrophulous children, 
we can commonly perceive much of the same habit and 
constitution that has been just now described. 

Some authors have supposed that the small-pox has a ten- 
dency to produce this disease; and Mr. De Haen asserts its 
following the inoculated, more frequently that the natural, 
small-pox. This last position, however, we can confident- 
ly affirm to be a mistake ; although it must be allowed, that 
in fact the scrophula does often come on immediately after 
the small-pox. It is, however, difficult to find any con- 
nection between the two diseases. According to my obser- 
vation, the accident only happens in children who have 
pretty manifestly the scrophulous disposition ; and I have 
had several instances of the natural small-pox coming upon 
children affected at the same time with scrophula, not only 
without this disease being any ways aggravated by the 
small-pox, but even of its being for some time after much 
relieved. 

1743.] The scrophula generally shows itself first at a 
particular season of the year ; and at some time between 
the winter and summer solstice; but commonly long before 
the latter period. It is to be observed further, that the 
course of the disease is usually connected with the course 
of the seasons. Whilst the tumors and ulcerations pecu- 
liar to this disease, appear first in the spring, the ulcers are 
frequently healed up in the course of the succeeding sum- 
mer, and do not break out again till the ensuing spring, to 
follow again with the season the same course as before. 

1744.] Frequently the first appearance of the disease is 
the tumid and chopped lip above-mentioned. Upon other 
occasions the first appearance is that of small spherical or 
oval tumors, moveable under the skin. They are soft, but 
with some elasticity. They are without pain ; and with- 
out any change in the color of the skin. In this state they 



556 PRACTICE OF PHYSIC, 

often continue for a long time ; even for a year or two, 
and sometimes longer* Most commonly they first appear 
upon the sides of the neck below the ears; but sometimes 
also under the chin. In either case, they are supposed to 
affect in these places the conglobate or lymphatic glands 
only ; and not at all the salivary glands, till the disease is 
very greatly advanced. The disease frequently affects, 
and even at first appears in, other parts of the body. In 
particular, it affects the joints of the elbows and ankles, or 
those of the fingers and toes. The appearances about the 
joints are not commonly, as elsewhere, small moveable 
swellings ; but a tumor almost uniformly surrounding the 
joint, and interrupting its motion. 

1745.] These tumors, as I have said, remain for some 
time little changed ; and, from the time they first appeared 
in the spring, they often continue in this way till the return 
of the same season in the next, or perhaps the second year 
after. About that time, however, or perhaps in the course 
of the season in which they first appear, the tumor becomes 
larger and more fixed ; the skin upon it acquires a purple, 
seldom a clear redness : but growing redder by degrees, 
the tumor becomes softer, and allows the fluctuation of a 
liquid within to be perceived. All this process, however, 
takes place with very little pain attending it. At length 
some part of the skin becomes paler ; and by one or more 
small apertures a liquid is poured out. 

1746.] The matter poured out has at first the appear- 
ance of pus, but it is usually of a thinner kind than that 
from phlegmonic abscesses; and the matter as it continues 
to be discharged, becomes daily less purulent, and appears 
more and more a viscid serum, intermixed with small pieces 
of a white substance resembling the curd of milk. By de- 
grees the tumor almost entirely subsides, while the ulcer 
opens more, and spreads broader: unequally, however, in 
different directions, and therefore is without any regular 
circumscription. The edges of the ulcer are commonly 
flat and smooth, both on their outside and their inner edge, 
which seldom puts on a callous appearance. The ulcers, 
however, do not generally spread much, or become deep- 
er ; but at the same time their edges do not advance, or 
put on any appearance of forming a cicatrix. 

1747.] In this condition the ulcers often continue for a 
long time ; while new tumors, with ulcers succeeding them 
in the manner above described, make their appearance in 



PRACTICE OF PHYSIC. 557 

different parts of the body. Of the first ulcers, however, 
some heal up, while other tumors and ulcers appear in 
their vicinity, or in other parts of the body : and in this 
manner the disease proceeds, some of the ulcers healing up, 
at least to a certain degree, in the course of summer, and 
breaking out in the succeeding spring: or it continues, by 
new tumors and ulcers succeeding them, in the spring sea- 
son, making their appearance successively for several years. 

1748.] In this way the disease goes on for several years ; 
but very commonly in four or five years it is spontaneously 
cured, the former ulcers being healed up, and no new tu- 
mors appearing : and thus at length the disease ceases en- 
tirely, leaving only some indelible eschars, pale and smooth, 
but in some parts shrivelled ; or, where it had occupied the 
joints, leaving the motion of these impaired, or entirely de- 
stroyed. 

1749.] Such is the most favorable course of this disease ; 
and with us, it is more frequently such, than otherwise : 
but it is often a more violent, and sometimes a fatal malady. 
In these cases, more parts of the body are at the same time 
affected ; the ulcers also seeming to be imbued with a pecu- 
liarly sharp acrimony, and therefore becoming more deep, 
eroding, spreading, as well as seldomer healing up. In such 
cases, the eyes are often particularly affected. The edges 
of the eyelids are affected with tumor and superficial ulce- 
rations ; and these commonly excite obstinate inflammation 
in the adnata, which frequently produces an opacity of the 
cornea. 

When the scrophula especially affects the joints, it some- 
times produces there considerable tumors ; in the abscesses 
following which, the ligaments and cartilages are eroded, 
and the adjoining bones are affected with a caries of a pe- 
culiar kind. In these cases, also, of more violent scrophu- 
la, while every year produces a number of new tumors and 
ulcers, their acrimony seems at length to taint the whole 
fluids of the body, occasioning various disorders ; and par- 
ticularly a hectic fever, with all its symptoms, which at 
length proves fatal, with sometimes the symptoms of a 
phthisis pulmonalis. 

1 750.] The bodies of persons who have died of this dis- 
ease show many of the viscera in a very morbid state ; and 
particularly most of the glands of the mesentery very much 
tumefied, and frequently in an ulcerated state. Commonly 



55S PRACTICE OF PHYSIC. 

also a great number of tubercles or cysts, containing mat- 
ter of various kinds, appear in the lungs. 

11 SI.] Such is the history of the disease ; and from thence 
it may appear, that the nature of it is not easily to be as- 
certained. It seems to be a peculiar affection of the lym- 
phatic system ; and this in some measure accounts for its 
connection with a particular period of life. Probably, 
however, there is a peculiar acrimony of the fluids that is 
the proximate cause of the disease; although o£ what na- 
ture this is, has not yet been discovered. It may perhaps be 
generally diffused in the system, and exhaled into the se- 
veral cavities and cellular texture of the body ; and there- 
fore, being taken up by the absorbents, may discover itself 
especially in the lymphatic system.- This, however, will 
hardly account for its being more confined to that system, 
than happens in the case of many other acrimonies which 
may be supposed to be as generally diffused. In short, its 
appearance in particular constitutions, and at a particular 
period of life, and even its being a hereditary disease, which 
so frequently depends upon the transmission of a peculiar 
constitution, are all of them circumstances which lead me to 
conclude, upon the whole, that this disease depends upon a 
peculiar constitution of the lymphatic system. 

1752.] It seems proper to observe here, that the scro- 
phula does not appear to be a contagious disease ; at least 
I have known many instances of sound children having had 
frequent and close intercourse with scrophulous children 
without being infected with the disease. This certainly 
shows, that in this disease the peculiar acrimony of it is 
not exhaled from the surface of the body, but that it de- 
pends especially upon a peculiar constitution of the system. 

1763.] Several authors have supposed the scrophula to 
have been derived from the venereal disease ; but upon no 
just grounds that I can perceive. In very many instances, 
there can hardly be any suspicion of the parents producing 
this disease having been imbued with siphylis, or with any 
siphylitic taint ; and 1 have known several examples of 
parents conveying siphylis to their offspring, in whom, how- 
ever, no scrophulous symptoms at any time afterwards ap- 
peared. Furthe**, the sympto ns of the two diseases are 
very different ; and the difference of their natures appears 
particularly from hence, that while mercury commonly 
and readily cures the siphylis, it does no service in scro- 
phula, and very often rather aggravates the disease. 



PRACTICE OF PHYSIC. 559 

1754-.] For the cure of scrophula, we have not yet learn- 
ed any practice that is certainly or even generally successful. 

The remedy which seems to be the most successful, and 
which our practitioners especially trust to and employ, is 
the use of mineral waters ; and indeed the washing out, 
by means of these, the lymphatic system, would seem to be 
a measure promising success: but in very many instances of 
the use of these waters, I have not been well satisfied that 
they had shortened the duration of the disease more than 
had often happened when no such remedy had been em- 
ployed. 

1755.] With regard to the choice of the mineral waters 
most fit for the purpose, I cannot with any confidence give, 
an opinion. Almost all kinds of mineral waters, whether 
chalybeate, sulphureous or saline, have been employed 
for the cure of scrophula, and seemingly with equal suc- 
cess and reputation : a circumstance which leads me to 
think, that, if they are ever successful, it is the elementary 
water that is the chief part of the remedy. 

Of late, sea water has been especially recommended and 
employed ; but after numerous trials, I cannot yet disco- 
rer its superior efficacy. 

1756.] The other remedies proposed by practical wri- 
ters are very numerous ; but, upon that very account, I 
apprehend they are little to be trusted : and as I cannot 
perceive any just reason for expecting success from them, 
I have very seldom employed them. 

Of late, the Peruvian bark has been much recommended : 
And as in scrophulous persons there are generally some 
marks of laxity and flaccidity, this tonic may possibly be 
of service ; but in a great variety of trials, I have never 
seen it produce any immediate cure of the disease. 

In several instances, the leaves of coltsfoot have appeared 
to me to be successful. I have used it frequently in strong 
decoction, and even then with advantage ; but have found 
more benefit from the expressed juice, when the plant could 
be had in somewhat of a succulent state, soon after its first 
appearance in the spring. 

1757.] I have also frequently employed the hemlock, 
and have sometimes found it useful in discussing obstinate 
swellings : but in this, it has also often disappointed me ; 
and I have not at any time observed that it disposed scro- 
phulous ulcers to heal. 

I cannot conclude the subject of internal medicines with- 



560 PRACTICE OF PHYSIC. 

out remarking, that I have never found, either mercury or 
antimony, in any shape, of use in this disease ; and when 
any degree of a feverish state had come on, the use of mer- 
cury proved manifestly hurtful. 

1758.] In the progress of scrophula, several external me- 
dicines are requisite. Several applications have been used 
for discussing the tumors upon their first coming on ; but 
hitherto my own practice, in these respects, has been at- 
tended with very little success. The solution of saccha- 
rnm saturni has seemed to be useful ; but it has more fre- 
quently failed: and I have had no better success with the 
spiritus Mmdereri. Fomentations of every kind have been 
frequently found to do harm ; and poultices seem only to 
hurry on a suppuration. I am doubtful if this last be ever 
practised with advantage ; for scrophulous tumors some- 
times spontaneously disappear, but never after any degree 
of inflammation has come upon them ; and therefore poul- 
tices, which commonly induce inflammation, prevent that 
discussion of tumors, which might otherwise have happened. 

Even when scrophulous tumors have advanced towards 
suppuration, I am unwilling to hasten the spontaneous 
opening, or to make it by the lancet ; because I apprehend 
the scrophulous matter is liable to be rendered more acrid 
by communication with the air, and to become more ero- 
ding and spreading than when in its inclosed state. 

1759.] The management of scrophulous ulcers has, so 
far as I know, been as little successful as that of the tu- 
mors. Escharotic preparations, of either mercury or cop- 
per, have been sometimes useful in bringing on a proper 
suppuration, and thereby disposing the ulcer to heal ; but 
they have seldom succeeded, and more commonly they 
have caused the ulcer to spread more. The escharotic 
from which I have received most benefit is burnt alum, and 
a portion of that mixed with a mild ointment, has been as 
useful an application as any I have tried. The applica- 
tion, however, that I have found most serviceable and very 
universally admissible, is that of linen cloths wetted with 
cold water, and frequently changed when they are becom- 
ing dry, it being inconvenient to let them be glued to the 
sore. They are therefore to be changed frequently during 
the day ; and a cloth spread with a mild ointment or plas- 
ter may be applied for the night. In this practice I have 
sometimes employed sea-water ; but generally it proved 



PRACTICE OF PHYSIC. 561 

too irritating ; and neither that nor any mineral water has 
appeared to be of more service than common water. 

1760.J To conclude what I have to offer upon the cure 
of scrophula, I must observe, that cold bathing seems to 
have been of more benefit than any other remedy that I 
have had occasion to see employed. 



CHAPTER II. 
OFSIPHYLIS, OR THE VENEREAL DISEASE. 

1761.] A FTER practitioners have had so much expe- 
m\. rience in treating this disease, and after so 
many books have been published upon the subject, it does 
not seem necessary, or even proper, for me to attempt any 
full treatise concerning it ; and I shall therefore confine 
myself to such general remarks, as may serve to illustrate 
some parts of the pathology or of the practice. 

1762.] It is sufficiently probable, that anciently, in cer- 
tain parts of Asia, where the leprosy prevailed, and in Eu- 
rope after that disease had been introduced into it, a disease 
of the genitals, resembling that which now commonly arises 
from siphylis, had frequently appeared : but it is equally 
probable, that a new disease, and what we at present term 
Siplnjlis, was first brought into Europe about the end of the 
fifteenth century ; and that the distemper now so frequently 
occurring, has been very entirely derived from that which 
was imported from America at the period mentioned.* 

1763.] This disease, at least in its principal circumstan- 
ces, never arises in any person but from some communica- 
tion with a person already affected with it. It is most com- 
monly contracted in consequence of coition with an infect- 
ed person ; but in what manner the infection is communi- 
cated, is not clearly explained. I am persuaded, that in 
coition, it is communicated without there being any open 
ulcer either in the person communicating or in the person 
receiving the infection ; but in all other cases, I believe it is 

• Various opinions have been held by different physicians about the origin of this disease} 

Some supposing it to have existed in the old world, while others thinlc it was imported from the 

new world, discovered by Columbus. The dispute produced many controversial tracts, from 

isal of which, the young practitioner can gain little advantageous knowledge. All that 

nly know avium the origin of the disease is, that it was first observed among the French, 

when they wire at Maples in the year 1 1'):5, and that it was brought into France b) the French 

who reiurned thither with Charles. Columbus landed at Paloson the 15ih of March in the same 

i n from Ins first vova°e. The disease therefore, if imported by Columbus' crew, 

must have spread rapidly through turope. 

4c 



562 PRACTICE OF PHYSIC. 

never communica4ed"in any other way than by a contact of 
nicer, either in the person communicating, or in the person 
receiving the infection. 

1764.] As it thus arises from the contact of particular 
parts, so it always appears first in the neighborhood of the 
parts to which the infecting matter had been immediately 
applied ; and therefore, as most commonly contracted by 
coition, it generally appears first in the genitals. 

1765] After its first appearance in particular parts, 
more especially when these are the genitals of either sex, 
its effects for some time seem to be confined to these parts ; 
and indeed, in many cases, never extends further. In other 
cases however, the infecting matter passes from the parts 
first affected, and from the genitals, therefore, into the blood- 
vessels ; and being there diffused, produces disorders in 
many other parts of the body. 

From this view of the circumstances, physicians have 
very properly distinguished the different states of the dis- 
ease, according as they are local or are more universal. To 
the former they have adapted appellations suited to the man- 
ner in which the disease appears : and to the other the ge- 
neral affection, they have almost totally confined the ap- 
pellations of Siphylis, Lues Venerea, or Pox. In the re- 
marks I am now to oiler, I shall begin- with considering the 
local affection. 

1766.] This local affection appears chiefly in the form of 
gonorrhoea or chancre. 

The phenomena of gonorrhoea, either upon its first com- 
ing on or in its after progress, or the symptoms of ardor 
uruire, chordee, or others attending it, it is not necessary 
for me to describe. I shall only here observe, that the chief 
circumstance to be taken notice of, is the inflamed state of 
the urethra, which I take to be inseparable from the disease. 

1767.] In these well known circumstances, the gonor- 
rhoea continues for a time longer or shorter, according to 
the constitution of the patient ; it usually remaining longest 
in the most vigorous and robust, or according to the pa- 
tient's regimen, and the care taken to relieve or cure the 
disease. In many cases, if by a proper regimen the irrita- 
tion of the inflamed state is carefully avoided, the gonor- 
rhoea spontaneously ceases, the symptoms of inflammation 
gradually abating, the matter discharged becoming of a 
thicker and more viscid consistence, as well as of a whiter 
color ; till at length, the flow of it ceases altogether ; and 



PRACTICE OF PHYSIC. 563 

whether it be thus cured spontaneously, or by art, the dis- 
ease often exists without communicating any infection to 
the other parts of the body. 

1768.] In other cases, hoAvever, the disease having been 
neglected, or by an improper regimen aggravated, it con- 
tinues with all its symptoms for a long time ; and produces 
various other disorders, in the genital parts, which, as com- 
monly taken notice of by authors, need not be described 
here. I shall only observe, that the inflammation of the 
urethra, which at first seems to be seated chiefly, or only, 
in its anterior parts, is in such neglected and aggravated 
cases spread upwards along the urethra, even to the neck 
of the bladder. In these circumstances, a more consider- 
able inflammation is occasioned in certain parts of the ure- 
thra ; and consequently, suppuration and ulcer are produc- 
ed by which the venereal poison is sometimes communicat- 
ed to the system, and gives rise to a general siphylis. 

1769.] It was some time ago a pretty general supposi- 
tion, that the gonorrhoea depended always upon ulcers of 
the urethra, producing a discharge of purulent matter ; and 
such ulcers do indeed sometimes occur in the manner that 
has been just now mentioned. We are now assured, how- 
ever, from many dissections of persons who had died when 
laboring under a genorrhoea, that the disease may exist, 
and from many considerations it is probable that it com- 
monly does exist, without any ulceration of the urethra ; 
so that the discharge which appears, is entirely that of a vi- 
tiated mucus from the mucous follicles of the urethra. 

1770.] Although most of the symptoms of gonorrhoea 
should be removed, yet it often happens that a mucous fluid 
continues to be discharged from the urethra for a long time 
after, and sometimes for a great part of a person's life. 
This discharge is what is commonly called a Gleet. 

With respect to this, it is proper to observe, that in some 
cases, when it is certain the matter discharged contains no 
venereal poison, the matter may, and often does put on that 
puriform appearance, and that yellow and greenish color, 
which appears in the discharge at the beginning and during 
the course of a virulent gonorrhoea. These appearances in 
the matter of a gleet which before had been of a less co- 
lored kind, have frequently given occasion to suppose that 
a fresh infection had been received : but I am certain that 
such appearances may be brought on by, perhaps, various 
ether causes ; and particularly, by intemperance in venery 



564 PRACTICE OF PHYSIC. 

and drinking concurring together. I believe, indeed, that 
this seldom happens to any but those who had before fre- 
quently labored under a virulent gonorrhoea, and have 
more or less of gleet remaining with them : but I must also 
observe, that in persons who at no period of their life had 
ever labored under a virulent gonorrhoea, or any other 
symptom of siphylitic affection, I have met with instances 
of discharges from the urethra resembling those of a viru- 
lent gonorrhoea. 

The purpose of these observations is, to suggest to prac- 
titioners what I have not found them always aware of, that 
in persons laboring under a gleet, such a return of the ap- 
pearances of a virulent gonorrhoea may happen without any 
new infection having been received, and consequently not 
requiring the treatment which a new infection might per- 
haps demand. When, in the cure of gonorrhoea, it was 
the practice to employ purgatives very frequently, and some- 
times those of the drastic kind, I have known the gleet, or 
spurious gonorrhoea, by such a practice much increased and 
long continued, and the patient's constitution very much 
hurt. Nay in order more certainly further to prevent mis- 
takes, it is to be observed, that the spurious gonorrhoea is 
sometimes attended with heat of urine, and some degree of 
inflammation ; but these symptoms are seldom considera- 
ble, and merely by the assistance of a cool regimen, com- 
monly disappear in a few days. 

1771.] With respect to the cure of a virulent gonorrhoea, 
I have only to remark, that if it be true, as I have mention- 
ed above, that the disease will often, under a proper regi- 
men, be spontaneously cured ; and that the whole of the 
virulent matter may be thus entirely discharged without the 
assistance of art ; it would seem that there is nothing re- 
quired of practitioners, but to moderate and remove that 
inflammation which continues the disease, and occasions all 
the troublesome symptoms that ever attend it. The sole 
business therefore of our art in the cure of gonorrhoea, is 
to take off the inflammation accompanying it : and this I 
think may commonly be done, by avoiding exercise, by 
using a low and cool diet, by abstaining entirely from fer- 
mented and spirituous liquors, and by taking plentifully of 
mild diluent drinks.* 

* This simp'e method of curing a gonorrhoea is, in many cases, sufficient ; but it can only be 
depended on w+ien the disease is slight and the patient of a healthy constitution. As every vi- 
rulent gonorrhoea is evidently pioduced by the action of the venereal ] oison, thejudicious prac- 
titioner wid seldom trust to this method without the use of mercurials after the inflammatory 
symptoms have been somewhat subdued. They ought to be given in such cases in very smaM 



PRACTICE OF PHYSIC 565 

1772.] The heat of urine, which is so troublesome in 
this disease, as it arises from the increased sensibility of the 
urethra in its inflamed state ; so, on the other hand, the ir- 
ritation of the urine has the effect of increasing the inflam- 
mation, and is therefore to be removed as soon as possible. 
This can be done most effectually by takingin a large quan- 
tity of mild watery liquors. Demulcents may be employ- 
ed ; but unless they be accompanied with a large quantity 
of water, they will have little effect.* Nitre has been com- 
monly employed as a supposed refrigerant : but, from 
much observation, I am convinced, that in a small quantity- 
it is useless, and in a large quantity certainly hurtful ;f and, 
for this reason, that every saline matter passing with the 
urine generally gives some irritation to the urethra. To 
prevent the irritation of the urethra arising from its increas- 
ed sensibility, the injection of mucilage or of mild oil into 
it has been practised ; but I have seldom found this of much 
service. 

1773.] In gonorrhoea, as costivencss may be hurtful, 
both by an irritation of the system in general, and of the 
urethra in particular, as this is occasioned always by the 
voiding of hardened faeces ; so costiveness is to be carefully 
avoided or removed ; and the frequent use of large glvsters 
of water and oil, I have found of remarkable benefit in this 
disease. If glvsters, however, do not entirely obviate cos- 
tiveness, it will be necessary to give laxitives by the mouth : 
which, however, should be of the mildest kind, and should 
do no more than keep the belly regular and a little loose, 
without much purging. J 

quantities, so as to produce only a slight effect on the mouth; and their use ought to be contin- 
ued till every symptom disappears. Mercury may be used either internally or externally, as oc- 
casion may require; if it does not affect the bowels nor purge, the common mercurial pill of the 
Edinburgh Pharmacopoeia is as good a formula as any we have in the shops. Its dose must be re- 
gulated by the effects it produces. In general, we begin with a four grain pill every night, and 
continue that quantity till the gums be slightly affected, or a coppery taste be perceived in the 
meuth. When either of these symptoms appear, we are certain that the mercury is received, 
in a sufficient quantity, into the general miss of the blood, for destroying the venereal virus, and 
then a pill may be given once in two or iluee days, so as to keep up the same slight affection of 
the mouth, but without increasing it. If the pill purges, we then are to have recourse to the 
strong mercurial ointment, half a drachm of which must be rubbed into the hams night and 
morning, till the mouth be affected in the manner above described. The patient ought to wear 
flannel drawers during the whole time of the continuing the rubbing, which ought to be regu- 
lated by the degree or affection perceived in the mouth. The use cither of the pill or of friction 
mu^ be continued eight or ten nays after every symptom of the disease has disappeared. 

•Linlseed tea, a very thin decoction of marsh-mallow root, or thin barley-water, will, in 
most cases, answer the intention sufficiently well. The common almond emulsion has been re- 
commended in these cases, and when taken in large quantities is certainly very eflkacious. It 
may be used as the patient's common drink. 

+ The use of nitre has been strongly recommended by many practical writers, in cases of sim- 
ple gonorrhoea unaccompanied with this symptom ; but it must be acknowledged, as the author 
justly observes, to be hurtful by its irritaling quality. It is certainly a refrigerant, and as such is 
useful in allaying the inflammatory symptoms; but it is inadmissible in cases where the ardot 
urinx is violent. 

t A tea-spoonful of the following electuary taken occasionally will keep the belly sufhcienUr 
open. 



566 PRACTICE OF PHYSIC. 

The practice of frequent purging, which was formerly 
so much in use, and is not yet entirely laid aside, has al- 
ways appeared to me to be generally superfluous, and of- 
ten very hurtful. Even what are supposed to be cooling 
purgatives, such as Glauber's salt, soluble tartar, and crys- 
tals of tartar, in so far as any part of them pass by urine, 
they, in the same manner as we have said of nitre, may be 
hurtful ; and so far as they produce very liquid stools, the 
matter of which is generally acrid, they irritate the rectum, 
and consequently the urethra. This last effect, however, 
the acrid, and in any degree drastic, purgatives, more cer- 
tainly produce. 

1774.] In cases of a gonorrhoea attended with violent in- 
flammation, blood-letting may be of service ; and in the 
case of persons of a robust and vigorous habit, in whom 
the disease is commonly the most violent, blood-letting may 
be very properly employed. As general bleedings, how- 
ever, when there is no phlogistic diathesis in the system, 
have little effect in removing topical inflammation ; so in 
gonorrhoea, when the inflammation is considerable, topical 
bleeding applied to the urethra by leeches, is generally 
more effectual in relieving the inflammation.* 

1775.] When there is any phymosis attending a gonor- 
rhoea, emollient fomentations applied to the whole penis are 
often of service. In such cases it is necessary, and in all 
others useful, to keep the penis laid up to the belly, when 
the patient either walks about or is sitting. f 

1776.] Upon occasion of frequent priapism and chordee, 
it has been found useful to apply to the whole of the penis 
a poultice of crumb of bread moistened with a strong so- 
lution of sugar of lead. I have, however, been often dis- 
appointed in this practice, perhaps by the poultice keeping 
the penis too warm, and thereby exciting the very symp- 
toms I wished to prevent. Whether lotions of the exter- 

R. Pulv. Jalap. JL 
Nitri 3ii- 
Elect. Lenitiv. §i. 
Syr. simpl. q. s. 
M. f. Elect. 

• The good effects of leeches in these cases are confirmed by experience. They may be ap- 
plied on the under side of the penis, and three or four thus applied have frequently produced 
amazing effects. The operation, however, is extremely paintul, and is seldom submitted to a 
second time by a patient who has once experienced it. 

+ In all cases of inflammation of the urethra these emollient applications give great relief. The 
common white bread poultice may be used during the night time or while the patient is in bed ; 
and warm flannels impregnated with lintseed tea while he is sitting up. 



PRACTICE OF PHYSIC. 567 

nal urethra with the solution of the sugar of lead, might 
be useful in this case, I have not properly tried.* 

1777.] With respect to the use of injections, so frequent- 
ly employed in gonorrhoea, I am persuaded, that the early 
use of astringent injections is pernicious ; not by occasion- 
ing a siphylis, as has been commonly imagined ; but by in- 
creasing and giving occasion to all the consequences of the 
inflammation, particularly to the very troublesome symp- 
toms of swelled testicles. When, however, the disease 
has continued for some time, and the inflammatory symp- 
toms have very much abated, I am of opinion, that by in- 
jections of moderate astringency, or at least of this gradu- 
ally increased, an end may be sooner put to the disease 
than would otherwise have happened ; and that a gleet, so 
readily occurring, may be generally prevented. f 

1778.] Besides the use of astringent injections, it has 
been common enough to employ those of a mercurial kind. 
With respect to these, although I am convinced that the in- 
fection producing gonorrhoea, and that producing chancres 
and siphylis, are one and the same; yet I apprehend, that 
in gonorrhoea mercury cannot be of use by correcting the 
virulence of the infection ; and therefore that it is not uni- 
versally necessary in this disease. I am persuaded, how- 
ever, that mercury applied to the internal surface of the 
urethra, may be of use in promoting the more full and free 
discharge of virulent matter from the mucous glands of it. 
Upon this supposition, I have frequently employed mercu- 
rial injections ; and, as I judge, Avith advantage ; those in- 

* The sugar of lead solution may perhaps be objected against on account of its stepping the 
discharge, and inducing a swelled testicle, which has sometimes followed us application. Wrap- 
ping the penis up in linen rags wet with cold water, frequently answers the puipose of prevent- 
ing the violence of the symptoms, as well as any more complicated application. The cold wet 
rags ought to be renewed whenever they grow warm. 

+ The practice of using astringent injections is extremely common ; but, as the author justly 
I. their use is frequently attended with disagreeable consequences. In general they al- 
ways do harm when used during the continuance of the inflammatory symptoms, or even too 
soon after these symptoms have disappeared, if, however, (after the inflammatory symptoim 
arc overcome, and mercury has been used for six weeks or two months in the manner described 
in the note on article 1771) the running still continues, we may then have recourse to these as- 
tringent injections.— They may be made of sugar of lead and white viiriol well diluted with wa- 
ter, as in lite following formula : 

R. Sacch. Saturn. 
Vitriol, ab. aa 5ss. 
Aq. font. § viii. f 
M. et cola per chartam. 

Half an ounce of this injection, slightly warmed, may be thrown up in the urethra twice:! 
«iay ; but if it produce any smarting, nought to be diluted with more water. — Solutions of c.op- 
. per have also been used with advantage in these cases, but they are of so corrosive a nature, as 
frequently to do harm, if not very much diluted. — An imprudent or too frequent use of any or 
these injections, especially if they are too strong or not sufficiently diluted, sometimes intlame- 
oreven excoriates the urethra, and hence much mischief arises. Thtf Cautious practitioner milst 
therefore never (fee them so strung as to produce much waning. 



568 PRACTICE OF PHYSIC. 

jections often bringing on such a state of the consistence 
and color of the matter discharged, as we know usually to 
precede its spontaneous ceasing. 1 avoid these injections, 
however, in recent cases, or while much inflammation is 
still present ; but when that inflammation has somewhat 
abated, and the discharge notwithstanding still continues 
in a virulent form, 1 employ mercurial injections freely. I 
employ those only that contain mercury entirely in a liquid 
form, and avoid those which may deposit an acrid powder 
in the urethra. That which I have found most useful is a 
solution of the corrosive sublimate in water ; so much di- 
luted as not to occasion any violent smarting, but not so 
much diluted as to give no smarting at all. \t is scarce 
necessary to add, that when there is reason to suspect there 
are ulcerations already formed in the urethra, mercurial 
injections are not only proper, but the only effectual reme- 
dy that can be employed. 

1 779.] With regard to the cure of gonorrhoea, I have only 
one other remark to offer. As most of the symptoms arise 
from the irritation of a stimulus applied, the effects of this 
irritation may be often lessened by diminishing the irrita- 
bility of the system; and it is well known, that the most 
certain means of accomplishing this is by employing opium. 
For that reason, I consider the practice both of applying 
opium directly to the urethra,* and of exhibiting it by the 
mouth, to be extremely useful in most cases of gonorrhoea. 

1780.] After thus offering some remarks with respect to 
gonorrhoea in general, I might proceed to consider parti- 
cularly the various symptoms which so frequently attend 
it; but it does not seem necessary for me to attempt this 
after the late publications of Dr. Foart Simmons, and of 
Dr. Schwediaur, who have treated the subject so fully, and 
with so much discernment and skill. f 

* Opium may be very conveniently applied to the urethra by injection ; and for this purpose 
a diluted solution of opium in water is preferable to a spirituous or vinous solution. A grain of 
opium dissolved in an ounce of water, and the solution strained, may be injected twice or thrice 
a day ; and thirty or forty drops of laudanum may be given every night at bed-time. 

+ As a swelled testicle frequently attends a suppressed gonorrhoea, it may be proper to give 
the young practitioner some directions concerning the management of it. Sometimes without 
any other preceding symptom, but generally on a premature stopping of a gonorrhoea, a pain 
is felt in the spermatic vessels and epididymis. The pain continuing, the vessels and epididy- 
mis begin to swell, and the pain and swelling are soon communicated to the testicle. In these 
cases, we must confine he patient to his bed, bleed him if the inflammatory diathesis appears 
to be universal ; but, if not, three or four leeches may be applied to the inflamed part. A brisk 
purge must be given, tor which purpose an ounce of Glauber's salt, •with a large quantity of wa- 
ter, answers sufficiently well. Cold pledgets soaked in a >olution of sugai of lead, described in 
the note on article 267, must be applied to the scrotum, and their place supplied with fre-h cold 
ones, as often as they grow warm by lying on the oart. A warm poultice of bread and milk, 
must be also applied to the glands penis or to the wriole penis. The patient mus; be liept on a 
very spare diet, using for his drink cold wa.er with a scruple of nure in each pint of ill Thu 
regimen generally allays the violence of the symptoms within twentv four hours: but. it will be 
necessary to continue lite use o» the cold pledgcu wd warm poultice for three or lour da/j or 



PRACTICE OF PHYSIC. 569 

1781.] The other form of the local affection of siphylis, 
is that of chancre. The ordinary appearance of this I need 
not describe, it having been already so often done. Of the 
few remarks I have to offer, the first is, that I believe chan- 
cres never appear in any degree without immediately com- 
municating to the blood more or less of the venereal poison : 
for I have constantly, whenever chancres had appeared, 
found, that unless mercury was immediately given inter- 
nally, some symptoms of a general siphylis did certainly 
come on afterwards; and though the internal use of mercury 
should prevent any such appearance, it is still to be pre- 
sumed that the poison had been communicated, because 
mercury could act upon it in no other manner than as 
diffused in the fluids. 

1782.] It has been a question among practitioners, upon 
the subject of chancres. Whether they may be immedi- 
ately healed up by applications made to the chancres, or 
if they should be left open for some time without any such 
application? It has been supposed, that the suddan healing 
up of chancres might immediately force into the blood a 
poison which might have been excluded by being discharged 
from the chancre. This, however, is a supposition that is 
very doubtful ; and, upon the other hand, I am certain, 
that the longer a chancre is kept open, the more poison it 
perhaps generates, and certainly supplies it more copiously 
to the blood. And although the above-mentioned supposi- 
tion were true, it will be of little consequence, if the inter- 
nal use of the mercury, winch I judge necessary in every 
case of chancre, be immediately employed. 1 have often, 
seen very troublesome consequences follow from allowing 
chancres to remain unhealed; and the symptoms of gene- 
ral siphylis have always seemed to me to be more conside- 
rable and violent in proportion as chancres had been suf- 
fered to remain longer unhealed. They should always, 
therefore, be healed as soon as possible; and that, by the 
only very effectual means, the application ef mercurials to 

longer, ami to repeat the purge. After the pain and swelling have been completely removed, 
the patient may sit up, but it will be prudent for him to use a suspensory bandage for the scrotum, 
as the weight of the testicles, by stretching the spermatic chords, will be apt to occasion the re- 
turn of all the symptoms. — Viomt times the gonorrhoea, if it had pieceded the swellings of the epi- 
dnlvmii and testicles, will be again brought on ; but, it likewise sometimes happens that, on dis- 
cussing the tumor in the scrotum, the glands of the groin begin 10 be painful and to swell. Itt 
these casfs we must apply cold pledgets to these glands as well as to the scrotum ; and rub, at 
uroe, some strong mercurial ointment on the inside of the thighs, in the course of the 
lymphatics going iu these glands; and, if the penis be not inflamed, hall a drachm or a scruple 
of merciiial ointment ought to be tubbed on the base of the g.ands penis in the inside of the. 
prepuce. 

Such it the general method of treating cases of this kind, and a prudent continuance of it sel- 
dom fails of lUCCCO. 

4 d 



570 



PRACTICE OF PHYSIC. 



the chancre itself. Those that are recent, and have not 
yet formed any considerable ulcer, may often be healed, by 
the common mercurial ointment;, but the most powerful 
means of healing them has appeared to me, to be the ap- 
plication of red precipitate in a dry powder.* 

1733.] When, in consequence of chancres, or of the 
other circumstances above mentioned, by which it may 
happen the venereal poison has been communicated to the 
blood, it produces many different symptoms in different 
parts of the body, not necessary to be enumerated and des- 
cribed here, that having been already done by many au- 
thors with great accuracy. 

J 784.] Whenever any, of those symptoms do in any de- 
gree appear, or as soon as it is known that the circumstan- 
ces which give occasion to the communication of the ve- 
nereal poison have taken place, I hold the internal use of 
mercury to be immediately necessary; and I am well per- 
suaded, the mercury employed without delay, and in suf- 
ficient quantity, will pretty certainly prevent the symp- 
toms which would otherwise have soon appeared, or will 
remore those that may have already discovered themselves. 
In both cases, it will secure the person from any future con- 
sequences of siphylis from that infection. 

1785.] This advice for the early and full use of mercury, 
I take to be the most important that can be given with res- 
pect to the venereal disease : and although I must admit 
that the virulence of the poison may be greater in one case 
than in another, and even that one constitution may be 
more favorable than another to the violence of the disease j 
yet I am thoroughly convinced, that most of the instances 
which have occurred of the violence and obstinacy of siphy- 
lis have been owing very entirely to the neglect of the ear- 
ly application of mercury ..f 

178G.] Whatever other remedies^ of siphylis may be 
known, or may hereafter be found out, I cannot pretend 

* Although chancres rmy be very speedily healed bv red precipitate alone, yet it will be neces- 
sary sometimes to use an oinrrneni made of the red precipitate and twice or thrice itsweight of 
fresh hog's lard: the pic pi ate.wili by this means be mote' constant!} kepi on the part. The 
practitioner, however, must be cautious lest he i , quantity of precipitate, which, by 

jts corrosive quality, sometimes increase* the ulcer it was meant to heal. — During theuse of this 
application, it will be necessary also to use mercury either internally or externally, in the man- 
ner described in the no'eon a'r.ieie 1771. — The application ot the lapis infernaits to chancres, 
comes recommended to us on 'he authority of some eminent practitioners. It is however a 
dangerous applical on, and frequently produces ulcer: hat are extremely difficult to heal. 

+ In a word, men In specific for siphylis, ?nd a sure antidote' against the venereal, 

poison. Ii i seldom fails of produi ing a cure ; and this ^ure will always be 

the more speed), in propoi lion as mercury has been uscn in the earlier stage of the disease. 

t V\e have no occasion 'o seek for other remedies than mercury : and the practitioner [wh» 
risks his pauent's health, and his own reputation, on. the uncertain, effects of other remedies' 
smely dtuems reprehension. 



PRACTICE OF PHYSIO. 571 

to determine; but I am well persuaded, that in most cases 
mercury properly employed will, prove a very certain and 
effectual remedy. With respect to others that have been 
proposed, I shall offer this remark only, that I have found 
the decoction of the mezereon contribute to the healing of 
ulcers which seemed to have resisted the power of mercury. 

1787.] With regard to the many and various prepara- 
tions of mercury, I do' not think it necessary to give any 
enumeration of them here, as they are commonly very well 
known and have been lately well enumerated by Dr. 
Schwediaur. The choice of them seems to be for the most 
part a matter of indifference; as I believe cures have been 
and still maybe effected by many different preparations, if 
properly administered. The proper administration* seems 
to consist, first, In the choosing those preparations which 
are the least ready to run off by stool ; and therefore the 
applications externally by unction are in many cases the 
most convenient. 2dly, In employing the unction, or in 
giving a preparation of mercury internally, in such quan- 
tity as may snow its sensible effects in the mouth. And, 'idly, 
•without carrying these effects to a greater length, In the 
continuing the employment of mercury for several weeks, 
or till the symptoms of the disease shall have for some 
time entirely disappeared. I say nothing of the regimen 
proper and necessary for patients during the employment 
of mercury, because I presume it to be very well known. 

1788.] Among the other preparations of mercury, I be- 
lieve the corrosive sublimate has often been employed with 
advantage: but I believe also, that it requires being con- 
tinued for a longer time than is necessary in the employ- 
ment of other preparations in the manner above proposed ; 
and I suspect it has often failed in making a cure, because 
employed while persons were at the Same time exposed to 
the free air. 

1789.] Upon these points, and others relative to the ad- 
ministration of mercury, and the cure of this disease, I 
might offer some particular remarks: but I believe they 
are generally understood ; and it is enough for me to say 
here, that if practitioners will attend, and patients will 
submit, to the general rules given above, they will seldom 
tail of obtaining a certain and speedy cure of the disease. 

* %t e the notes on article 1771. 



572 PRACTICE OF PHYSIC. 



CHAPTER III. 
OF SCURVY. 

1790.] HPHIS disease appears so frequently, and the ef- 
jL fects of it are so often fatal in fleets and ar- 
mies, that it has very properly engaged the particular at- 
tention of physicians. It is indeed surprising that it had 
no sooner attracted the especial notice both of statesmen 
and physicians, so as to have produced those measures and 
reflations that might prevent the havock which it so often 
occasions. Within these last fifty years, however, it has 
been so much attended to and studied, that we might sup- 
pose every circumstance relating to it so fully and exactly 
ascertained, as to render all further labor upon the subject 
superfluous. This perhaps may be true ; but it appears to 
me, that there are still several circumstances regarding the 
disease not agreed upon among physicians, as well as differ- 
ent opinions formed, some of which may havehad abad effect 
upon the practice ; and this seems to me to be so much the 
case, that I hope I shall be excused in endeavoring here to 
state the facts as they appear to me from the best authori- 
ties, and to offer remarks upon opinions which may influ- 
ence the practice in the prevention and cure of this disease, 

1791.] With respect to the phenomena of the disease, 
they have now been so fully observed, and so accurately 
described, that there is no longer any doubt in discerning 
the disease when it is present, or in distinguishing it from 
almost every other ailment. In particular it seems now to 
be fully determined, that there is one disease only, intitled 
to the appellation of Scurvy ; that it is the same upon the 
land as upon the sea ; that it is the same in all climates and 
seasons, as depending every Avhere upon nearly the same 
causes ; and that it is not at all diversified, either in its phe- 
nomena or its causes, as had been imagined some time ago. 

1792.] The phenomena of scurvy, therefore, are not to 
be described here, as it has been so fully and accurately 
done elsewhere ; and I shall only endeavor to ascertain those 
facts with respect to the prevention and cure of the disease 
which seem not yet to be exactly agreed upon. And first, 
with respect to the antecedents that may be considered as 
the remote causes of the disease. 



PRACTICE OF PHYSIC. 513 

1793.] The most remarkable circumstances amongst the 
antecedents of this disease is, that it has most con.inonly 
happened to men living very much on salted meats ; and 
whether it ever arise in any other circumstances, is extreme- 
ly duubtful. These meats are often in a putrescent state ; 
and to tue circumstance of thelong continued use of animal 
food in a putrescent and somewhat indigestible state, the dis- 
ease has bee" esoeciallv attributed. Whether the circum- 
stauu of the uu.it' being salted, has any effect in produc- 
ing the disease, otherwise than by being rendered more in- 
digestible, is a question that remains still in dispute. 

1194."' It seems tome, that the salt concurs in producing; 
the effect ; for there is hardly any instance of ti 
appearing unless where salt meats had been employed, and 
scarcely an example where the long Continued use vi these 
did not produce it ; besides all which, there e in- 

stances where, by avoiding salt meats, or by diminishing 
the proportion of them in diet, while other circumstances 
remained much the same, the disease was prevented from 
appearing. Further, if it may be admitted as an argument 
upon this subject, 1 shall hereafter endeavor to show, that 
the large use of salt has a tendency to aggravate and increase 
the proximate cause of scurvy. 

17.95.] It must, however, be allowed, that the principal 
circumstance in causing scurvy, is the living very much and 
very long upon animal food, especially when in a putrescent 
state ; and the clear proof of this is, that a quantity of fresh 
vegetable food will always certainly prevent the disease. 

1796.] While it has been held, that, in those circum- 
stances in which scurvy is produced, the animal food em- 
ployed was especially hurtful by its being of difficult diges- 
tion, this opinion has been attempted to be confirmed, by 
observing, that the rest of the food employed in the same 
circumstances was also of difficult digestion. This is sup- 
posed to be especially the case of unfermented farinacea 
which so commonly makes a part of the sea-diet. JBut I ap- 
prehend this opinion to be very ill-founded ; for the unfer- 
mented farinacea, which are in a great proportion the food 
of infants, of women, and of the greater part of mankind, 
can hardly be supposed to be food of difficult digestion . 
and with respect to the production of scurvy, there are facts 
which show, that unfermented farinacea, employed in large 
proportion, have had a considerable effect in preventing the 
disease. 



574 PRACTICE OF PHYSIC. 

1797.] It has been imagined, that a certain impregnation 
of the air upon the sea had an effect in producing scurvy. 
But it is altogether improbable r for the only impregnations 
which could be suspected, are those of inflammable or me- 
phitic air ; and it is now well known, that these impregna- 
tions are much less in the air upon the sea than in that upon 
the land ; besides, there are otherwise many proofs of the 
salubrity of the sea-air. If therefore, sea-air have any ef- 
fect in producing scurvy, it mu=,t be by its sensible qualities 
of cold or moisture. 

1798.] That cold has an effect in favoring the production 
of scurvy, is manifest from hence, that the disease is more 
frequent and more considerable in cold than in warm cli- 
mates and seasons ; and that even warm clothing has a con- 
siderable effect in preventing it. 

1799.] Moisture may in general have an effect in favor- 
ing the production of scurvy, where that of the atmosphere 
in which men are placed is very considerable : but the ordi- 
nary moisture of the sea-air is far from being such. Pro- 
bably it is never considerable-, except in the case of unusual 
rains ; and even then it is perhaps by the application of 
moisture to the bodies of men in damp clothing only that it 
has any share in the production of scurvy. At the same 
time, I believe, there is no instance of either cold or mois- 
ture producing scurvy, without the concurrence of the faul- 
ty sea diet. 

1800.] Under those circumstances which produce scur- 
vv, it commonly seems to occur most readily in the persons 
who are the least exercised ; and it is therefore probable, 
that confinement and want of exercise may have a great 
share in producing the disease. 

1801.] It appears that weakness, in whatever manner 
occasioned, is favorable to the production of scurvy. It is 
therefore probable, that unusual labor and fatigue may often 
have some share in bringing it on : and upon the same ac- 
count, it is probable, that sadness and despondency may in- 
duce a weakness of the circulation ; and thereby, as has 
been remarked, be favorable to the production of scurvy. 

1802.] It has also been observed, that persons negligent 
in keeping their skin clean by washing and change of cloth- 
ing, are more liable than others to be affected with scurvy. 
1803.] Several of these causes, now mentioned, concur- 
ring together, seem to produce scurvv ; but there is no pro- 
per evidence that any one of them alone will produce it, or 



PRACTICE OF PHYSIC. 515 

that all the other uniting together will do it, w ithout the 
particular concurrence of the sea diet. Along with this, 
however, several of the other circumstances mentioned, 
have a great ellect in producing It sooner, and in a more 
considerable degree, than should otherwise have happened 
from the diet alone. 

1804.] From this view of the remote causes, it Avill rea- 
dily appear, that the prevention of the disease may in some 
measure djpe id upon the avoiding of those circumstances, 
which we have enumerated as contributing to bring on the 
disease sooner than it would otherwise come on. At the 
same time, the only effectual means will be, by avoiding 
the diet of salted meats ; at least by lessening the proportion 
of these, and using meat preserved otherwise than by salt ; 
by using in diet any kind of esculent vegetable matter that 
can be obtained ; and especially by using vegetable matters 
the most disposed to acescency, such as malt ; and by 
drinking a Urge quantity of pure water. 

1805.] The cure of scurvy seems now to be very well 
ascertained ; and when the necessary means can be obtained, 
the d'sease is commonly removed very quickly. The chief 
means is a food of fresh and succulent vegetables, and those 
almost of any kind that are at all esculent. Those most 
immediately eifectual are the acid fruits, and, as being of 
the same nature, all sort of fermented liquor. 

1806.] The plants named alkalescent, such as those of 
the garlic tribe and of the tetradynamiie,* arc also particu- 
larly useful in the cure of this disease ; for, notwithstanding 
their appellation, they m the first part of their fermentation 
undergo an acescency, and seem to contain a great deal of 
acescent matter. At the same time, they have generally in 
their composition an acrid matter that readily passes by 
urine, probably by perspiration ; and by promoting both 
excretions, are useful in the disease. It is probable, that 
son) plants of the coniferous tribe, such as the spruce hr, 
and others possessed of a diuretic power, may likewise be 
of some use. 

1807.] It is sufficiently probable, that milk of every 
kind, and particularly its productions whey and butter- 
milk, may prove a cure of this disease. 

•The plants of ihis etas ought to bo used in large quantities-, an J raw. The more active spe- 
r-cre^s, G;ivJea uess.Scuivy-grass: the milder species are, 
Radishes, Turnip . Cal 

;i amiicorbotii s of different classes; as Malt, Spinach, 
the ung sho ifc. of Mops, Purslain, with se- 
hers.— All these ire>h vegetal lesmust be eaten in large (|uantnies; they ousjht indeed !• 
constitute the patient's chief food, and his drink may be a fresh infusion of Malt. 



576 PRACTICE OF PHYSIC. 

] 808.] It has been common in this disease to employ the 
fossil acids ; but there is reason to doubt if they be of 
anv service, and it is certain they are not effectual reme- 
dies. They can hardlv be thrown in such quantity as to 
be useful antiseptics ; and as they do not seem to enter in- 
to the composition of the animal fluids, and probably pass 
off unchanged by the excretions, so they can do little in 
changing the state of the fluids. 

1809. f The great debilitv which constantly attends scur- 
vy, has naturailv led physicians to employ tonic and 
strengthening medicines, particularly the Peruvian bark ; 
but the etficacy of it seems to me very doubtful. It is sur- 
prising how soon the use of a vegetable diet restores the 
strength of scorbutic persons ; which seems to show that the 
preceding debility had depended upon the state of the 
fluids ; and consequently, till the sound state of these can be 
restored, no tonic remedy can have much effect: but as the 
Peruvian bark has little power in changing the state of the 
fluids, so it can have little effect in scurvy. 

1810.] I shall conclude my observations upon the me- 
dicines employed in scurvy, with remarking, that the use 
of mercury is always manifestly hurtful. 

1811.] After having observed that both the prevention 
and cure of this disease are now very well known, it may 
seem unnecessary to enter into much discussion concerning 
its proximate cause : but as such discussions can hardly be 
avoided, and as false opinions may in some measure cor- 
rupt the practice, J shall venture to suggest here what ap- 
pears to me most probable upon the subject. 

1812.] Notwithstanding what has been asserted by some 
eminent persons, I trust to the concurring testimony of the 
most part of the authors upon the subject, that in scurvy 
the fluids suffer a considerable change. 

From these authors we learn, that in the blood drawn 
from the veins of persons laboring under the scurvy, the 
crassamentum is different both in color and consistence 
from what it is in healthy persons ; and that at the same 
time the serum is commonly changed both in color and 
taste. The excretions also, in scorbutic persons, show a 
change in the state of the fluids. The breath is fetid : the 
urine is always high colored, and more acrid than usual ; 
and if that acrid exsudation from the feet, which Dr. 
Hulme takes notice of, happens especially in scorbutic 
persons, it will be a remarkable proof to the same purpose. 



PRACTICE OF PHYSIC. 577 

But however this may be, there is evidence enough that 
in scurvy the natural state of the fluids is considerably 
changed. Further, I apprehend it may be confidently 
presumed from this, that the disease is brought on by a 
particular nourishment introduced into the body, and is as 
certainly cured by the taking in of a different diet. In the 
latter case, the diet used has no other evident operation, 
than that of giving a particular state and condition of the 
fluids. 

1813.] Presuming therefore, that the disease depends 
upon a particular condition of the fluids of the body, the 
next subject of inquiry is, What that condition may be ? 

With this view I must observe, that the animal economy 
has a singular power of changing acescent aliments, in such 
a manner, as to render them much more disposed to putre- 
faction ; and although, in a living state, they hardly ever 
proceed to an actually putrid state ; yet in man, whose 
aliment is of a mixed kind, it is pretty certain, that if he 
"were to live entirely upon animal food, without a frequent 
supply of vegetable aliment, his fluids would advance fur- 
ther towards putrefaction than is consistent with health. — 
This advance towards putrefaction seems to consist in the 
production and evolution of a saline matter which did not 
appear in the vegetable aliment, and could not be produc- 
ed or evolved in it, but by carrying on its fermentation, 
to a putrefactive state. That this saline state is constantly 
in some measure produced and evolved by the animal pro- 
cess, appears from this, that certain excretions of saline 
matter are constantly made from the human body, and are 
therefore presumed necessary to its health. 

From all this, it may be readily understood, how the 
continual use of animal food, especially when already in a 
putrescent state, without a mixture of vegetable, may have 
the effect of carrying the animal process too far, and par- 
ticularly of producing and evolving a larger proportion of 
saline matter. That such a preternatural quantity of saline 
matter does exist in the blood of scorbutic persons, appears 
from the state of the fluids above-mentioned. It will be a 
confirmation of all this to observe, that every interruption 
of perspiration, that is, the retention of saline matter, con- 
tributes to the production of scurvy; and this interruption 
is especially owing to the application of cold, or to what- 
ever else weakens the force of the circulation, such as the 
neglect or want of exercise, fatigue, or despondency of the 

4e 



57S PRACTICE OF PHYSIC. 

mind. It deserves indeed to be remarked here, that one 
of the first effects of the scurvy once induced, is very soon 
to occasion a great debility of the system, which occasions 
of course a more rapid progress of the disease. How the 
state of the fluids may induce such a debiiity is not well 
understood ; but that it does depend upon such a state of 
the fluids, is rendered sufficiently presumable from what 
has been said above with regard to both the causes and the 
cure of scurvy. 

1814.] It is possible that this debility may have a great 
share in producing several of the phenomena of scur- 
vy; but a preternaturally saline, and consequently dissolv- 
ed, state of the blood, will account for them with more 
probability ; and I do not think it necessary to persons 
who are at all accustomed to reason upon the animal eco- 
nomy, to explain this matter more fully. I have only to 
add, that if my opinion in supposing the proximate cause 
of scurvy to be a preternaturally saline state of the blood, 
be at all founded, it will be sufficiently obvious, that the 
throwing into the body along with the aliment an unusual 
quantity of salt, may have a great share in producing 
the disease. Even supposing such salt to suffer no change 
in the animal body, the effect of it may be considerable ; 
and this will be rendered still more probable, if it may be 

f>resumed, that all neutral salts, consisting of a fixed alka- 
i, are changed in the animal body into an ammomacal 
salt ; which I apprehend to be that especially prevailing in 
scurvy. If I be at all right in concluding, that meats, from 
being salted, contribute to the production of scurvy, it 
will readily appear, how dangerous it may be to admit the 
conclusion from another theory, that they are perfectly 
innocent. 

1815.] Having thus endeavored to explain what relates 
to the cure of scurvy in general, I judge it proper to leave 
to other authors, what relates to the management of those 
symptoms which require a particular treatment. 



181 



CHAPTER IV. 

OF J A U N D1C E. 

6.] T HAVE here passed over several of the titles 
A in my nosology, because they are diseases not 



PRACTICE OF PHYSIC. 579 

of this island. In these, therefore, I have no experience ; 
and without that, the compiling from other writers is al- 
ways extremely fallacious. For these reasons I omit 
them; and shall now only offer some remarks upon the 
subject of jaundice, the last in order that I can possibly 
introduce in my course of Lectures. 

1817.] The jaundice consists in a yellow color of the 
skin over the whole body, and particularly of the adnata 
of the eyes. This yellow color may occur from different 
causes : but in the jaundice, hereafter to be more exactly 
characterised, I judge it to depend upon a quantity of bile 
present in the mass of blood ; and which, thrown out upon 
the surface, gives its own proper color to the skin and eyes. 
1818.] That the disease depends upon this we know 
particularly and certainly from the causes by which it is 
produced. In order to explain these, I must observe, that 
bile does not exist in its proper form in the mass of blood, 
and cannot appear in this form till it has passed the secre- 
tory organ of the liver. The bile, therefore, cannot ap- 
pear in the mass of blood, or upon the surface of the body, 
that is, produce jaundice from any interruption of its se- 
cretion ; and accordingly, if jaundice does appear, it must 
be in consequence of the bile, after it had been secerned, 
being again taken into the blood-vessels. 

This may happen in two ways ; either by an interruption 
of its excretion, that is, of its passage into the duodenum, 
which by accumulating it in the biliary vesssels, may give 
occasion to its passing again into the blood-vessels ; or it 
may pass into these, \v its being absorbed from the ali- 
mentary canal, when it happens to be accumulated there 
in an unusual quantity. How far the latter cause can take 
place, or in what circumstances it does occur, I cannot 
clearly ascertain, and 1 apprehend that jaundice is seldom 
produced in that manner. 

1819.] The former cause of stopped excretion may be 
understood more clearly ; and we have very certain proof 
of its being the ordinary, and indeed the almost universal, 
cause of this disease. Upon this subject it will be obvious, 
that the interrupted excretion of the bile must depend upon 
in obstruction of the ductus communis choledothus ; the 
most common cause of which is a biliary concretion form- 
ed in the gall-bladder, and from thence falling down into 
the ductus communis, it being ot the same time rtf such a 
size as not to pass readily through that duct into the duo- 



580 PRACTICE OF PHYSIC. 

denum. This duct may likewise be obstructed by a spas- 
modic constriction affecting it: and such spasm may hap- 
pen, either in the duct itself, which we suppose to be con- 
tractile ; or in the duodenum pressing the sides of the duct 
close together ; or, lastly, the duct may be obstructed by a 
tumor compressing it, and that arising either in the coats 
of the duct itself, or in any of the neighboring parts that 
are, or may come to be, contiguous to it. 

1820.] When such obstruction happens, the secreted bile 
must be accumulated in the biliary ducts; and from thence 
it may either be absorbed and carried by the lymphatics 
into the blood-vessels, or it may regurgitate into the duets 
themselves, arul pass from them directly into the ascending 
cava. In either way, it comes to be diffused in the mass of 
blood; and from thence may pass by every exhalant vessel, 
and produce the disease in question. 

1821.] I have thus shortly explained the ordinary pro- 
duction of jaundice : but it must be observed further, that 
it is at all times accompanied with certain other symptoms, 
such as a whiteness of the faces alvince, which we readdy 
account for from the absence of bile in the intestines ; and 
generally, also, with a certain consistence of the faeces, the 
cause of which is not so easy to explain. The disease is 
always accompanied also with urine of a yellow color, or 
at least with urine that tinges a linen cloth with a yellow' 
color. These are constantly attending symptoms ; and 
though not always, yet there is commonly, a pain felt in 
the epigastrium, corresponding, as we suppose, to the seat 
of the ductus communis. The pain is often accompanied 
with vomiting ; and even when the pain is not considerable, 
a vomiting sometimes occurs. In some cases, when the 
pain is considerable, the pulse becomes frequent, full, and 
hard, and some other symptoms of pyrexia appear. 

1822.] When the jaundice is occasioned by tumors of 
the neighboring parts compressing the biliary duct, I be- 
lieve the disease can very seldom be cured. That such is 
the cause of jaundice, may with some probability be sup- 
posed, when it has come on in consequence of other dis- 
eases which had subsisted long before, and more especially 
such as had been attended with symptoms of obstructed 
viscera. Even when the jaundice has subsisted lono- with- 
out any intermission, and without any pain in the epigas- 
trium, an external compression is to be suspected. 

1823:1 In such circqmstances, I consider the disease as 



PRACTICE OF PHYSIC. 531 

incurable ; and it is almost only when the disease is occa- 
sioned by biliary concretions obstructing the biliary duct, 
that we may commonly expect relief, and that our art may 
contribute to the obtaining it. Such cases may be gene- 
rally known by the disease frequently disappearing and 
returning again ; by our finding, after the former accident,' 
biliary concretions amongst the f\eces ; and by the disease 
being frequently accompanied with pain of the epigastrium, 
and with vomitings arising from such pain. 

1824.] In these cases, we know of no certain and im- 
mediate means of expediting the passage of the biliary con- 
cretions. This is generally a work of time depending up- 
on the gradual dilatation of the biliary duct; and it is sur- 
prising to observe from the size of the stones which some- 
times pass through, what dilatation the duct will admit of. 
It proceeds, however, faster or slower upon different occa- 
sions ; and therefore the jaundice, after a various duration, 
often ceases suddenly and spontaneously. It is this which 
has given rise to the belief, that the jaundice has been cur- 
ed by such a number and such a variety of different reme- 
dies. Many of these, however, are perfectly inert, and 
many others of them such as cannot be supposed to have 
any effect in expediting the passage of a biliary concretion. 
1 snail here, therefore, take no notice of the numerous re- 
medies of jaundice mentioned by the writers on the Materia 
Mediea, or even of those to be found in practical authors ; 
but shall confine myself to the mention of those that may 
■with probability be supposed to favor the passage of the 
concretion, or remove the obstacles to it which may occur. 
1825. ] In the treatment of this disease, it is in the first 
place, to be attended to, that as the distension of the bilia- 
ry duct, by a hard mass that does not easily pass through it, 
may excite inflammation there ; so, in persons of tolerable 
vigor, blood-letting may be an useful precaution ; and when 
much pain, together with any degree of pyrexia, occurs, 
it becomes an absolutely necessary remedy. In some in- 
stances of jaundice accompanied with these symptoms, I 
have found the blood drawn covered with an inflammatory 
crust as thick as in cases of pneumonia. 

1826.] There is no means of pushing forward a biliary 
concretion that is more probable than the action of vomit- 
ing ; which, by compressing the whole abdominal viscera, 
and particularly the full and distended gall-bladder and bi- 
liary vessels, may contribute, sometimes gently enough, to 



582 PRACTICE OF PHYSIC. 

the dilatation of the biliary duct. Accordingly vomiting 
has often been found useful for this purpose ; but at the 
same time it is possible, that the force exerted in the act of 
vomiting may be too violent, and therefore gentle vomits 
ought only to be employed. And either when, by the long 
continuance of the jaundice, it may be suspected that the 
size of the concretion then passing is large ; or more espe- 
cially when pain attending the disease gives apprehension 
of inflammation, it may be prudent to avoid vomiting al- 
together. 

1827.] It has been usual in the jaundice to employ pur- 
gatives ; and it is possible that the action of the intestines 
may excite the action of the biliary ducts, and thus favor 
the expulsion of the biliary concretion : but this, I think, 
cannot be of much effect ; and the attempting it by the fre- 

?uent use of purgatives, may otherwise hurt the patient. 
or this reason I apprehend, that purgatives can never be 
proper, excepting when there is a slow and bound belly.* 

1828.] As the relaxation of the skin contributes to relax 
the whole system, and particularly to relieve the constric- 
tion of subjacent parts ; so, when the jaundice is attended 
with pain, fomentations of the epigastrium may be of service. 

1829.] As the solids of the living body are very flexible 
and yielding ; so it is probable, that biliary concretions 
would in many cases find the biliary duct readily admit of 
such dilatation as to render their passage through it easy, 
were it not that the distension occasions a preternatural 
spasmodic contraction of the parts below. Upon this ac- 
count, opium is often of great benefit in jaundice ; and the 
benefit resulting from its use, proves sufficiently the truth 
of the theory upon which the using of it has been founded. 

1830.] It were much to be wished, that a solvent of bi- 
liary concretions, which might be applied to them in the 
gall-bladder or biliary ducts, was discovered ; but none such, 
so far as I know, has yet been found ; and the employment 
of soap in this disease. I consider as a frivolous attempt. 
Dr. White of York has found a solvent of biliary concre- 
tions when these are out of the body ; but there is not the 
least probability that it could reach them while lodged 
within. 

* The ?ood effects of purgatives; in renn i oncretions in (he duct, are sufficient"? 

apparc It is true, i all purgatives have not this effect, eroe* 

riaily sue!; av lire'of a ^enlit: ut e», h wever, whose actii n U 

with' good effects. Some 



INDEX 



TO THE 



TWO VOLUMES. 

N. B. The Cyphers refer to the number of the Paragraphs. 



A, 



BSCESS, 250 

Abscesses and ulcers, the causes 
of their different states, 254 

Acids employed in fever, 134 

refrigerant in fever, ibid 

Action of the heart and arteries, 
how increased for prevent- 
ing the recurrences of the 
paroxysms of intermitting 
fever, 230 

Adynamya, 1170 

Amenorrhea, 994 

from retention, 995 

when occurring, 997 

symptoms of, 998 

causes of, 999 — 1000 

cure of, 1001 — 5 

from suppression, 995 

when occurring, 1007 

symptoms of, 1009 

causes of, 1007 — 8 

cure of, 1010 — 11 

Amentia, 1 599 

Anasarca, 16C9 

the character of, ibid 

phenomena of, 1669 — 74 

cure of, 1675 — 97 

distinguished from Leuco- 
phlegmatia, 1670 

St. Anthony s Fire. See Erythema. 

Antimonial Emetics, employed 
in fevers, 181 

their different kinds, ibid 

the administration of them 
in fevers, 183 — 186 

Antiphlogistic Regimen, 129 

how conducted, l;)0 

when employed in intermit- 
tent fever, 234 

Antispasmodics, employed in 
fevers, 152 — 187 

Aphtha, 732 

Apoplexy, 1093 



Apoplexy, distingushed from 

palsy, ibid 

distinguished from syncope ibid 
predisponent cause of, 1094 
exciting causes of, 1097-1 1 M-l$ 
proximate causes of, 1099—20 
Serosa, proximate cause of Ills 
prognostic, 1121—22 

frequently ending in he- 
miphlegia, 1121 

prevention of, 1123 

whether sanguine or serous, 
stimulants hurtful in it 1135-36 
from powers that destroy 
the mobility of the ner- 
vous power, 1137 
cure of, 1 1 30 — 38 
Apyrexia, 24 
Ascites, 1710 
character of, ibid 
its various seat, 1711 — 12 
the phenomena of, 1713 — 14 
its particular seat difficultly 

ascertained, 1715 

the cure of, 1716 — 18 

Asthma, 1374 

phenomena of, 1376 

exciting causes of, 1S82 

proximate cause of, 138.S 

distinguished from other 

kinds of dyspnoea, 138f 

sometimes occasions phthi- 
sis pulmonalis, 1387 
frequently ends in hydro- 
thorax, ibid 
seldom entirely cured, 1 388 
Astringents, employed in in- 
termittent fevers, 231 
joined with aromatics, em- 
ployed in intermittent 
fevers ibid 
joined with bitters, employ- 
ed in intermittent fevers, ibid 



I N D E X. 



jttrabiUs, 1028 

■Atrophia ab alvi fluxu, 1608 

debilium, 1607 

\ inanitorum, 1608 

infantilis, 1606 

lactantium, ibid 

lateralis, 1G07 — 12 

a leucorrhoea, 1608 

nervosa, 1 607 

nutricum, 1608 

a ptyalisma ibid 

rachitica, 1606 

senilis, 1607 — 12 

Aura Epileptica, 1307 

B 
Bitters employed in intermit- 
tent fevers, 231 
joined with astringents, em- 
ployed in intermittents, ibid 
Blistering, its effects, 189 — 197 
its mode of operation in the 

cure of fevers, 1 90 — 1 94 

when to be employed in 

fevers, 195 

where to be applied in fevers 196 
Bloodletting, the employment 

of it in fevers, 138 — 143 

the circumstances directing 

its use in fevers, 1 42 

the administration of it in 

fevers. 143 

when employed in intermit- 
tent fevers, 234 
C 
Cachexies, character of the 

class, 1600 

Cachexy, the term, how appli- 
ed by authors, 1601 
Calculus Renalis, 428 
Calx nitrata antimonii, its use 

in fevers, 183 — 185 

Canine Madness y 1526 

the cure of, 1526 — 1528 

Cardialgia, 1428 

Carditis, 383 

of the chronic kind, ibid 

Cams, 1093 

Cataphora, ibid 

Catarrh, 1045 

predisposition to, 1046 

symptoms of, 1047 

remote causes of, 1 046 

proximate cause of, 1056 



Catarrh, cure of, 1064 

produces phthisis, 1054 

passes into pneumonia, 1053 
produces a peripneumonia 
notha, 1055 

Catarrh, contagious, 1061 

Catarrhus, sujfocativus, 376 

Chancre, method of treating, 1782 
Chicken Pox, 630 

how distinguished from 
small pox, 631 

Ckincough, 1403 

contagious, ibid 

frequently accompanied 

with fever, 141 1 

phenomena of, 1405 

prognostic in, 1414 

cure of, 1415 

Chlorosis, 997 

Cholera, 1454 

symptoms of, 1454 — 57 

remote causes of, 1559 — 61 

proximate cause of, 1455 

cure of, 1463 — 65 

Chorea, 1348 

phenomena of, 1348 — 54 

cure of, 1355 

Chronic weakness, 1 1 9 1 

Cceliaca, 1494 

Cold, its operations, 88 

absolute, ibid 

relative, 89 

its general effects on the 

human body, 90 — 91 

its morbid effects, 92 

moderates the violence of 

reaction in fever, 133 

its tonic power, how to be 
employed in fevers, 205 

Cold drink, an useful tonic in 
fevers, 206 

the limitation of its use in 

fevers, 207 

air applied in fevers, 208 

water applied to the surface 
of the body in fevers, 205-209 
Colic, 1436 

symptoms of, 1436 — 39 

proximate cause of, 1440 

cure of, 1442 

Devonshire, 1452 

of Poitou, ibid 

cure of, 1459 



INDEX. 



Com*, 1093 

Comata, 1092 

Contagions, 78 

their supposed variety, 79 

Convulsions, 1253 

Corpulency, 1622 

Cynanche, S00 

maligna, 311 

parotidia, 332 

pharyngaa, 331 

tonsillaris, 301 

trachealis, 318 

as affecting infants, 322 — 329 

the cure of it, 330 

Cystitis, 430 

D 
jDtfji.r, critical, in fevers, 107 — 124 
noncritical, 113 

Death, the causes of in general 100 
the direct causes of, ibid 

the indirect causes of, ibid 

the causes of in fever, 101 

Debility in fevers, the symp- 
toms of, 104 
how obviated, 202 
Delirium in general, 1530 — 51 
in fever of two kinds, 45 
or insanity without fever, 

1551—58 
Diabetes, 1 500 

symptoms of, 1505 — 19 

remote causes of, 1505 

proximate cause of, 1511—13 
cure of, 1514 

Dixta Aquea, 157 

Diarrhea, 1 466 

distinguished from dysen- 
tery, 1467 
distinguished from cholera 1468 
proximate cause of, 1469 
remote causes of, 1472 — 94 
cure of, 1495 — 1504 
biliosa, 1481 
colliquative, 1 502 
mucosa, 1489 
Diathesis phlogistica, 62 — 247 
how removed, 266 
Diluents, their use in fevers, 

154—158 
Diseases, the distinguishing of 

them, how attained, 2 

the prevention of them, on 
what founded, 3 



Diseases, the cure of them oh 

what founded, 4 

Dropsies, 1646 

in general the cause of 

them, 1647 

of the breast. See Hydro- 
thorax. 
of the lower belly. See 
Ascites. 

Dysentery, 1066 

contagious, 1074 

remote causes of, 1071 

proximate cause of, I07i? 

cure of, 1079 

use of mild cathartics to be 

frequently repeated in it, ibid 
rhubarb improper in it, ibid 

Dysenteria alba, 1069 

Dysmenorrhea, 1015 

Dyspepsia, 1190 

remote causes of, 1 198 

proximate cause of, 1193 

cure of, 1201 

flatulence in it, cure of, 1221 
heartburn in it, cure of, ibid 
pains of stomach in, cure of, ibid 
vomiting in it, cure of, ibid 

Dyspnea, 1 366 

E 

Effluvia, human, 85 

from marshes, ibid 

Emaciations, 1 60 1 

causes of, 1603 — 19 

cure of 1620 

Emansio mensium, 997 

Emetics, suited to the cure of 

fevers, 174 

their effects, 176 — 180 

a mean of removing spasm, 170 
the administration of in fe- 
vers, 175 
their use in intermittent fe- 
vers, 230 — 23 S 

Emprosthotonos, 1267 

Enteritis, 404 

phlegmonic or erithematic, ibid 
causes of, 406 

cure of, 408 

Epilepsy, 128$ 

phenomena of, 1284 

proximate cause of, 1285 

remote causes of, 1286 

predisponent causes of, isi l 



4 F 



I N D E X. 



pilepsy, sympathic, 


1317 


cure of, 


1318 


idiopathic, 


1S17 


cure of, 


IS 20 


pistaxis, 


805 


the causes of it, 


807 



the various circumstances 

of it, 806 — 817 

the management and cure 

of, 813— S28 

Erisipelas, 274 

of the face, 707 

• symptoms of, 704 — 707 

prognosis of, 705 

proximate cause of 696 

cure of, 707 — 710 

phlegmonodes in different 

parts of the body 711 

attending putrid fever, 7 1 2 

Erythema, 274 

Exanthemata, 584 

Exercise, useful in intermit- 
tent fevers, 231 
F 
Fainting. See Syncope. 1 1 70 
Fatuity, 1530 
Fear, a remote cause of fever, 97 
Fever, 8 
strictly so called, the cha- 
racter of, 8 — 32 
phenomena of, 8 
remote causes of, are of a 

sedative nature, 36 

proximate cause of, S3 

atony of the extreme vessels, 
a principal circumstance 
in the proximate cause of 
it, 43 — 44 

spasm, a principal part in 

the proximate cause of it, 40 
general doctrine of, 46 

the causes of death in it, lol 
the prognosis of, 99 

indications of cure in, 126 

differences of, 53 

continent, 28 

continued, 27 

inflammatory, 67 

miliary. See Miliary Fever. 
nervous, 67 

bilious, 7 1 

scarlet. See Scarlet Fever. 
putrid, 72 



Fever, named synocha, «7 

synochus, 69 

typhus, 67 

hectic, 74 

intermittent, the parox- 
ysms of, described, 10 
the cold stage of, 11 
the hot stage of, ibid 
the sweating stage of, ibid 
of a tertian period, 25 
of a quartan period, ibid 
of a quotidian period, ibid 
caused by marsh effiuvia, 84 
bile not the cause of it, 51 
cure of, 228 
its paroxysms, how pre- 
vents, 229 
attended with phlogis- 
tic diathesis-, 234 
attended with congesti- 
tion in the abdominal 
viscera, ibid 
remittent, 2G 
Fluxes, without fever. See 

Profluvia. 
Fluor albous. See Leucor- 

rhaa. 
Fomentation of the lower ex- 
tremities, its use in fevers, 199 
Fomites of contagion, 82 

Functions, intellectual, disor- 
ders of, 1 529 — SO 
G 
Gangrene of inflamed parts, 

the cause of, 255 — 25$ 

marks of the tendency to 257 

marks of its having come on, ib 

Gastritis, 384 

phlegmonic or erythematic, 385 

phlegmonic, the seat of, ibid 

the symptoms of, 386 

the causes of, 387 

the cure of, 39S — 397 

erythematic, how discover'd 400 

the seat of, 385 

the cure of, 40 i 

Gastrodynia 1428 

Gleet, J 770 

Gonorrhoea ] 766 

phenomena of, 1768 — 70 

cure of, 1771 — 79 

Gout, the character of, 49 1 

a hereditary disease, 499 



INDEX. 



Gout, distinguished from 

rheumatism, 525 

predisponent causesof 492 — 499 
occasional causes of, 501 — 504 
proximate cause of, 526 — 532 
not a morbific matter, 528 

Regular, described, 505 — 5 1 7 
pathology of, 532 

cure of, 563—572 

no effectual or safe reme- 
dy yet found for the 
cure of it, 538 

me licines employed for it 555 
whether it can be radi- 
cally cured, 5S9 
treatment in 'he inter- 
vals of paroxysms, 541 
treatment in the time of 

paroxysm 3, 559 

regimen dining the pa- 
roxysms, 560 
external applications, 

how far safe, 567 — 5G8 
blood-letting in the in- 
tervals of paroxysms, 552 
blood-letting in the 

time of paroxysms, 562 
costiveness hurtful, 558 

laxatives to be employed, ibid 
effects ofalkalines, 557 

of Portland powder, 556 
Irregular, 5 1 7 

Atonic, 573 — 578 

pathology of, 533 

cure of, 579 — 58 i 

Retrocedent, 52 1 

pathology of, 534 

cure of, 579 — 58 1 

Misplaced, 522 

pathology of, 535 

cure of, 582 — 583 

Translated, two particular 
cases of, 524 

H 
Hematemesis, 1016 

arterial and venous, 1 026 

from obstructed menstru- 
ation, 1019 
from suppression of the 

hemorrhoidal flux, 1024 

from compression of the 

vasabrevia,bythe spleen, 1026 
obstruction of the liver, 1027 



Hameturia, i,038 

idiopathic, improbable 1 032-33 
calculosa, i036 

cure of, 1037 

violenta, 1038 

from suppression of ac- 
customed discharges, 1040 
putrida 1 042 

spuria et lateritia, 1043 

ifgia, 1 139 

causesof, 1 j40 

frequently occasioned by 

apoplexy, 1141 

frequently alternates with 

apoplexy, 1143 

cure of, 1151 

stimulants, of ambiguous 

use in, 1 159 

stimulants, external, in, 1160 
Hemoptysis, 

the symptoms of 837 — 839 

the causes of, 759-62-8-9-835 
how distinguished from o- 

ther spittings of blood 840-44 
cure of, 845 — 5 1 

lltcmorrhagia uteri, 965 

Ilemorrhagy, 

active or passive 734 
character of, 735 
arterial, 743 
venous, 767 
the causes of the different 
species appearing at dif- 
ferent periods of life,,749-772 
general phenomena of, 737-742 
the remote causes of, 77S 
cure of, 775 
whether to be attempt- 
ed by art, 775 — 80 
prevention of the first at- 
tacks, or of the recur- 
rence of, 781 — 788 
treatment of when pre- 
sent, 788 — 804 
symptomatic, 1014 
Hemorrboides vesica, 1041 
Hemorrhois 

external and internal, 924 

phenomena of, 924 — 930 

nature of the tumors, 9.3 1 

causes of, 9S2 — 942 

acquire a connection with 
the system, 942 — 943 



INDEX. 



Hamorrhois, particularly 

with the stomach, 945 

cure of, 946 — 964 

Hepatirrbxa, 1482 

Hepatitis, 411 

acute and chronic, ibid 

acute symptoms of, 4l2 — 4i4 
combined with pneu- 
monic inflammation, 4 . 5 
remote causes of it, ibid 

seat of, 417 

various exit of pus pro- 
duced in, 420 
cure of, 42 1 
chronic, the seat of, 417 
how discovered, 422 
Hoopingcough. See Chin- 

cough, 1403 

Horror, impression of, em- 
ployed in intermittent 
fevers, 23 1 

Human effluvia, the cause of 

fever, 8 1 

body, its temperature, 83 

body has a power of ge- 
nerating heat, ibid 
Hydrophobia, 1 526 
Hydrot borax, 1698 
where seated, 1699 
symptoms of, 1702 — 04 
often combined with uni- 
versal dropsy, 1705 
proximate cause of 1 707 
cure of, 1708—09 
paracentesis, in it, when 

proper, 1709 

Hyparcatbarsis 1478 

Hypochondriasis, 1223 

phenomena of, ibid 

distinguished from dys- 
pepsia, 1227 
proximate cause of, J 23 1 
cure of, 1233 
treatment of the mind in, 1 245 
Hysteria, 1515 
symptoms of 1 5 1 6 — i 7 
paroxysm or fit described, ibid 
rarely appears in males, 1518 
how distinguished from 

hypochondriasis, 1 5 1 9 — 20 
proximate cause of, 1523 

analogy between and epi- 
lepsy* 1524 



Hysteria, cure of, 1525 

libidinosx, 15-8 

Hysteric, disease. See Hysteria. 

I 
James 1 powder, its use in 

fever, 183 

Jaundice, 1 8 1 6 — I 7 

causes of, 18 1 7 — 22 

cure of, 1824 — 30 

Icterus, See Jaundice. 
Iliac passion. See Ileus. 
Ileus, H38 

Impetigincs, 1738 

character of the order, ibid 

Indigestion. See Dyspepsia. 
Inflammation, phenomena of, 235 
internal, the marks of, 236 

the state of the blood in, 237 
the proximate cause of, 239 
not depending upon a len- 

tor of the blood, 241 

spasm the proximate cause 

of, 243—248 

terminated by resolution, 249 
by suppuration, 250 

by gangrene, 255 

by scirrhus, 258 

by effusion, 259 

by blisters, 260 

by exsudation, 261 

the remote causes of, 262 

the cure of in general, 264 

by resolution, ibid 

the cure of, when tending 
to suppuration, 268 — 70 

when tending to gan- 
grene, 271 
its' general divisions, 273 
more strictly cutaneous, 274 
of the bladder. See Cystitus. 
of the brain. See Phrenitis. 
of the heart. See Carditis. 
of the intestines. See Enteritis. 
of the kidneys. See Nephritis. 
of the liver. See' Hepatitis. 
of the lungs. See Pneumonia. 
of the pericardium. See Peri- 
carditis. 
of the peritonaeum. See Peri- 
tonitis. 
of the spleen. See Splenitis. 
of the stomach. See Gastritis. 
of the uterus, 43 1 



INDEX. 



Insanity, 


1636 


causes of, 1 55 1 


—58 


of different species, 


1558 


partial and general, differ- 




ence of, 


1576 


Intemperance in drinking, 




> a remote cause of fever, 


97 


Intermission of fever, 


24 


Interval of fever. 


ibid 


Intumescentix, 


1621 


character of the order, 

K 
King's evil. . See Scrophula. 

L 
Leucophlegmatia, 


ibid 




1670 


Leucorrhcea, 


984 


character of, 


985 


appearance of the matter 


discharged in, 986 


—991 


the causes of, 


987 


the effects of, 


989 


the cure of, 


992 


Letbargus, 


1093 


Lientery 


1470 


Looseness. See Diarrhoea. 




M 




Madness. See Mania. 




Canine. See Canine. 




Mania, 


1559 


the symptoms of, 


ibid 


the remote causes of, 1 56o-62 


the treatment of, 1 563-75 



Menorrhagia, 965 

active or passive, ibid 

when a disease, 967 — 74 

effects of, 971 

proximate cause of, 976 

remote causes of, 977 

cure of, 979 

Menses, immoderate flow of 

them. See Menorrhagia. 
Metallic tonics, employed in 
intermittent fevers, 23 I 

salts, refrigerant, 1 36 

Meteorismus 1634 

Miasmata, ' 8 

Miliary fever, 

the general history of, 7 1 3-7 1 4 
of two kinds, red and white, 7 1 5 
white, symptoms of, 7 1 6 — 7 
the cure of, 
Morbus cteliacus, 
mucosus, 
niger, 

N 
Nephritis, 

the symptoms of, 
the remote causes of, 
the cure of, 
Nervous Diseases. See Neuroses. 
Neuroses, 1089 

Neutral salts, diaphoretic in 
fevers, 159—161 

135 



occurring in sanguine 

temperaments, 1577 

in sanguine temperaments, 
. cure of, 1578 

Marcores, 1 60 1 

Marsh effluvia, cause of fever, 84 
Measles, 632 

the symptoms of, 636 — 64 1 

the nature of, 643 

the cure of, 644—649 

of a putrid kind, 642 

Medicine, the institutions of, 4 
Melcena, 1016 

Melancholia, ' 576 

how distinguished from hy- 
pochondriasis, i58« — S9 
the character of, 1 58S— 90 
the proximate cause of, ■ 79 1 
the treatment of, 1 593-98 
Melancholic temperament, 1230 
Melancholy. See Melancholia. 



719 
1494 
1069 
1028 

425 

ibid 

426 
.429 



1622 

1599 

278 

ibid 



refrigerant in fevers, 
Nosology, Methodical, 

O 
Obesity, when a disease, 
Oneirodynia, 
Ophthalmia, 
membranarum, 

its different degrees 279—280 

its remote causes, 280 

the cure of, 288—290 

tarsi, 278 

the cure of, 288—290 

Opiates, employed in the hot 

stage of intermittent fevers 233 

in the interval of intermit 

tent fevers, 

Opisthotonos. See Tetanus. 



231 



Palpitation of the heart, 
the phenomena of, 
the causes of, 
the cure of, 



1356 
ibid 
1357 
1364 



I N D E X. 



Palsy ; 1 1 39 

distinguish, from apoplexy 1093 
causes of, 1140 

Paracentesis in ascites, when 

to be attempted, 1718 

hydrothorax, when proper, 170:) 
Paraphrenias, 343 

Paroxysm of intermittent fe- 
vers, the recurrence how 
to be prevented, 229 

Pemphigus, 73 1 

Pericarditis, 383 

Peripneumonia not ha, 37 S 

sympto.ns of, 379 

pathology of, 380 

the cure of, 38 1 — 382 

some sy nptoms explained, 350 
Peripneu mony, 34 2 

Perito.vi-s, 384 

Peruvian bark, not a specific, 213 
its tonic power, 2 1 4 

when proper in fever, 8 1 5 

how effectually employed, 216 
the administration of, in 

intermittent fevers, 232 

the tonic chiefly employed 
in intermittent fevers, ibid 

Petechia, 73S 

Phlegmasia* 235 

Phleg-non, 274 

Phrenitis, 29 1 

the character of, 293 

the remote causes of, 294 

the cure of, 295— .99 

Pbrensy. See Phrenitis 
Physic, practice of, how taught, 1 
theory of, how employed, 4 
Physconia, 1719 

Phthisis pulmonalisy the gene- 
ral character of, 852 
always with an ulceration 

of the lungs, 854 

the pus coughed up in, how 

distinguished from mucus, 855 
accom > with hectic fever, 856 
the various causes of it, 862 
from haemoptysis, 863 — 864 
from pneumonia, 865 — S68 
from catarrh, 869—872 

from asthma, 874 

from tubercles, 875—881 

from calcareous matter in 
the iungs, 883 



Phthisis pulm. if contagious, 885 
from tubercles, symptoms, 888 
its different duration, 895 

the prognosis in, 896 

the cure of, 898— 9-23 

the treatment of when aris- 
ing from tubercles, 905 — 920 
the palliation of symp- 
toms, 9 21—923 
Plague, general character of, 664 
phenomena of, ibid 
principal symptoms of, 666 
proximate cause of, 667 
prevention of, 669 — 684 
cure of, 685 — 694 
Pleurisy, 341 
Pleurosthotonos. See Tetanus. 
Pneumonia, or Pneumonic In- 
flammation, 334 
general symptoms of, 335 — 339 
seat of, 340 — 344 
prognosis of, 352 — 360 
cure of, 36 1 
the management of blood- 
letting in the cure of, 362-367 
the use of purgatives in, 370 
the use of emetics in, 371 
the use of blisters in, 372 
the means of promoting 

expectoration in, 373 

the use of sweating in, 374 

the use of opiates in, 375 

Polysarcia, when a disease 1622 
cure of, 1624 — 26 

Proflwvia, 1044 

character of the class, ibid 

Pulse, the state of the, du- 
ring the paroxysm of an 
intermittent fever, 12 

Purging, its use in continu- 
ed fevers, 144 
intermittent fevers, 234 
Pus, how produced, 250 
Putrescency of the fluids in 

fever, the symptoms of, 1 05 
the tendency to in fever, 
how tobe corrected, 222-226 
Pylorus, Scirrhous. See Dyspepsia. 
Pyrexia, character of the class, 6 
orders of the class, 7 

Pyrosis, 1428 

symptoms of, 1 432 

proximate cause of, 1 43 1 



INDEX. 



Pyrosis, remote causes of, HS3 

cure of, 1435 

Pyrosis Suecica of SauvagCS, 1429 

Q 

Quinsy. See Cynanche. 

Rachitis, 1720 

its origin, 1721 

remote causes of, 1722—1724 
phenomena of, 1725 

proximate cause of, 1726-1729 
cure of, 1730 — 17S7 

Reaction of the system, 59 

violent in fever, symptoms, 103 
violence of, how moderated, 127 
Refrigerants, the use of them 

in fever, 134 

Remedies, table of those em- 
ployed in continued fevers, 227 
Remission of fever, 26 

Resolution of inflammation, 

how produced, 249 

Respiration, changes, during 

paroxysm of an intermittent, 13 
Revolution, diurnal, in the hu- 
man body, 55 
Rheumatism, acute or chronic, 432 
Acute, remote causes of, 435 
proximate cause of, 444 — 459 
symptoms of, 438 — 446 
cure of, 460—469 
Chronic, symptoms of, 449 
how distinguished from the 

acute, 450 

proximate cause of, 471 

cure of, 472 — 475 

how distingui shed from go ut, 52 5 

Rickets. See Rachitis. 

Rose. See Erythema. 

S 
Scarlet Fever, 650 

the symptoms of, 655 

different from cynanche ma- 
ligna, 650 — 654 
the cure of, 656 — 663 
Scrophtila, 1739 
the phenomena of, 1739 — 1750 
the proximate cause of, 1751 
not contagious, 1752 
not arising from the lues 

venerea, \~.'?> 

the cure of, 1754 — GO 

Mesenterica t 1«07 



Scurvy, 179« 

remote causes of, 1793— l&os 

cure of 1805 — 10 

proximate cause of, 1812 — 15 

Sinapisms, effects of them, 197 

Skin, affections of. See Impetigines. 

Small Pox, gen. character of, 586 

symptoms of distinct kind, 583 

of confluent kind, 589-592 

general differences between 

distinct and confluent, 59* 
causes of these differ- 
ences, 594—599 
prognosis in, 592 
cure of, 600—629 
inoculation of, 601 
the several practices of, 
which it consists, 602 
importance of several prac- 
tices belonging to, 603—614 
management of small pox 
received byinfection, 615-629 
Soda, 1428 
Spasm, internal, means of 

removing in fevers, 152 — 187 
the proximate cause of in- 
flammation, 24S — 248 
Spasmodic affections without 

fever, 1251 

of the animal functions, 1254 
of the vital functions, 1355 

of the natural functions, 1 429 
Sphacelus, 255 

Splenitis, 424 

Stimulants, when to be em- 
ployed in fevers, 217 
their use in intermittent 
fevers, 230 
Stomach, its consent with the 
vessels on the surface of 
the body, 44 
Sudorifics, arguments for their 
use in fevers, 163 — 167 
against their use in fevers, 164 
Suppuration of inflamed parts, 

the causes of, 251 

the marks of tendency to, ibid 
formed, the marks of, ibid 

Surface of the body, its con- 
sent with the stomach, 44 
Swellings, general. See Intumei- 
centia. 
adipose, 1622 



INDEX. 



Swellings, flatu'cnt, 1627 

watery. See Dropsies. 
Sweating, when hurtful in 

continued fevers, 165 

rules for the conduct of 

in continued fevers, 168 

use of in intermittent fe- 
vers, 2:30 
Syncope, phenomena of 1170 
remote causes of, 1173 — 1178 
predisposition to, 1184 
cure of, 1189 
distinguished from apo- 
plexy, 1093 
Synocha. See Fever. 
Synochus. See Fever. 
Syphilis, 1761 
originally from America, 1762 
how propagated, 1763 
and gonorrhoea, how distin- 
guished, 1765 
cure of, 1784 — 1789 



Tabes, a hydrope, 
a sanguifluxu, 
dorsalis, 


1610 

1609 
1611 


glandularis, 
mesenterica, 


1607 
ibid 


nutricum, 


1609 


rachialgia, 
scrophulosa, 


1607 
ibid 



Tartar Emetic, its use m 

fevers, 185 

Tetanus, 1257 

remote causes of 1268 

cure of, 1270 

pissileum Barbadense, or 

Barbadoes tar, in 1280 

lateralis, 1268 

Tonic medicines employed in 

continued fevers, 2 1 1 

do. in intermittent fevers, 231 

Toothach, how far different 

from Rheumatism, 476 — 479 
symptoms of, 477 

predisposition to, 480 

remote causes of, 480—48 1 



proximate cause of, 482 

cure of, 484 — 490 

Trismus. See Tetanus. 

Nascentium, 1282 

Tussis. See Catarrh. 
Tympanites, character of 1628 
different species of, 1629 — 31 
intestinalis 1629 

enterophysodes ibid 

abdominalis ibid 

asciticus ibid 

phenomena of, 1633 

proximate cause of, 1636— S7 
cure of, 1638 — 45 

Typhus. See Fever. 
the species of, 70 

V 
Vapors, or low spirits. See 

Hypochondriasis. 
Venereal Disease See Siphylis. 
Venery, excess in, a remote 

cause of fever, 97 

Vesania, in genera!, 1529 

Vis medicatrix natures, 38 

St. Vitus' Dance. See Chorea. 
Vomiting of Blood. See He- 
matemesis. 
effects of in continued fe- 
vers, 172 — 173 
the use of in intermitting 
fevers, 230 — 34 
U 
Urine, bloody. See Hematuria. 
Urticaria, the history and 
treatment of, 729 
W 
Water-Brash. See Pyrosis. 
Whites. See Leucorrhcea. 
Warm-Bathing, the effects of 

in fever, 198 

administration of in fevers 199 
marks of the good effects 200 
Wine, the most proper stimu- 
lant in fevers, 218 
its convenient use in fevers 219 
when hurtful or useful in 
fevers, 220 



THE END. 



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